Download Texas Plan to Reduce Cardiovascular Disease and Stroke

 2
Forward
information and expert advice on the development of
this updated Plan. The Partnership’s Steering
Committee is committed to the Plan’s successful
implementation and invites you to join in its efforts to
reduce heart disease and stroke in Texas.
The fourth edition of the Texas Plan to Reduce
Cardiovascular Disease and Stroke (Plan) provides a
set of goals and strategies for addressing heart
disease and stroke in Texas. The 2013 Plan has been
updated with the help of community stakeholders from
across the state and a group of experts representing
state and community-level public health agencies, the
health care industry, worksite wellness professionals,
the non-profit and academic sectors. These
stakeholders provide a wide range of local and
organizational perspectives. Their efforts helped
identify heart disease and stroke prevention,
detection, and treatment priorities to address in Texas.
The Cardiovascular Disease and Stroke Program of
the Texas Department of State Health Services’
Health Promotion and Chronic Disease Prevention
Section provides technical assistance, training and
consultation on the development of policy and
environmental change strategies to decrease risk
factors for heart disease and stroke and encourage
Texans to establish a heart and stroke healthy
lifestyle. The Program works collaboratively with the
Texas Council on Cardiovascular Disease and Stroke
and the Texas Cardiovascular Disease and Stroke
Partnership to educate, inform and facilitate action
among Texans to reduce the human and financial toll
of cardiovascular disease and stroke.
The Plan provides an overview of the current state of
cardiovascular disease and stroke in Texas and
identifies priority objectives for organizations to
incorporate into their strategic plans. The Plan
includes summary of findings from the heart disease
and stroke prevention system assessment, as well as
information on mortality, morbidity, prevalence, and
related risk factors.
Please use this Plan for developing your own
cardiovascular disease and stroke program objectives.
Implement the evidence-based strategies described in
this report to bring about improved cardiovascular and
brain health for all Texans. Your participation in and
adoption of the strategies outlined in this Plan are
critical to the success of this collaborative effort.
Many strategies will be coordinated at the state level,
but others can only be effectively implemented at the
local or organizational level. The success of this Plan
and of heart disease and stroke prevention efforts in
Texas requires partners in all sectors and at all levels
to work collaboratively.
The Texas Council on Cardiovascular Disease and
Stroke was established by the Legislature and its
members are appointed by the Governor. The Council
continues to work with stakeholders to implement the
Plan and promote the mission of the Council: that is,
“to educate, inform and facilitate action among Texans
to reduce the human and financial toll of
cardiovascular disease and stroke.”
The Texas Cardiovascular Disease and Stroke
Partnership, a group of dedicated stakeholders from
all across Texas, has worked diligently to provide
3
Acknowledgements
This Plan was updated through joint planning meetings and coordination among organizations participating in
the Texas Cardiovascular Disease and Stroke Partnership, the Texas Council for Cardiovascular Disease and
Stroke, and the Cardiovascular Disease and Stroke Program of the Texas Department of State Health
Services.
A number of staff from the Department of State Health Services played key roles in coordinating meetings,
facilitating planning, and writing and editing drafts of the Plan.
Health Promotion and Chronic Disease Prevention Section &
Cardiovascular Disease and Stroke Program
Rosemary Ang, MS, MT – Epidemiologist
Maria Benedict - Program Specialist
Nimisha Bhakta, MPH - Epidemiologist
Cecily Brea, MEd – Program Specialist
Brett Spencer – Statewide Wellness Coordinator
Julie Stagg, MSN, RN, IBCLC, RLC – State Breastfeeding Coordinator
Tom Stephan, BA, MFA - Information Specialist
Lucina Suarez, PhD - Acting Assistant Commissioner - Prevention and Preparedness Services Division
Katie Wiechnicki, RN, MPH – Program Coordinator and Plan Writer
4
Members of the Texas Council on Cardiovascular Disease and Stroke contributed their time and expertise
to fulfill their charge with maintaining and implementing a cardiovascular disease plan for the state of Texas.
Pam Akins, JD
Lisa Glenn, MD
Paula Gomez (Incoming member 2012)
Michael Hawkins, MD
Suzanne Hildebrand (Incoming member 2012)
Bob Hillert, MD, FACC, FACP, FAHA
Deanna Hoelscher, PhD, RD, LD, CNS (Departing member 2012)
Floristene Johnson, MS (Incoming member 2012)
Ann Quinn Todd, RN, MSN, NE-BC, FAHA
J. Neal Rutledge, MD, FACR
Jan Skinner, MPH
Thomas Tenner, Jr, PhD
Louis West, LFACHE
Members of the Texas Cardiovascular Disease and Stroke Partnership also contributed their time and
expertise to the Texas Plan to Reduce Cardiovascular Disease and Stroke update process. A list of the
Partnership Steering Committee members can be found in Appendix III.
The majority of data for the Plan were obtained from the Center for Health Statistics, Texas Department of
State Health Services.
5 Table of Contents
Goal 3: Health Systems Interventions ...................... 41 Goal 4: Surveillance and Epidemiology .................... 44 Assessing Progress 46 Texas Benchmark Indicators, Baselines, and 2017 Targets ...................................................................... 46 Forward
3 Acknowledgements 4 Table of Contents 6 Executive Summary 7 Call to Action ............................................................... 8 References 53 Appendix I – Resources for Action 57 Appendix II – Data Sources 60 Appendix III – Texas Partnership Steering
Committee 61 Appendix IV - Invitation to Participate
63 Introduction 9 The State of Cardiovascular Disease and Stroke
in Texas
11 Diseases of the Heart ................................................ 11 Stroke ........................................................................ 12 Disparities in Cardiovascular Disease and
Stroke 13 High Risk Populations ................................................ 13 Access to Care ........................................................... 16 Addressing Health Disparities ................................... 19 Risk Factors for Cardiovascular Disease and
Stroke 19 High Blood Pressure .................................................. 20 High Blood Cholesterol ............................................. 21 Diabetes .................................................................... 23 Tobacco Use and Exposure to Second Hand Smoke . 24 Overweight and Obesity ........................................... 24 Unhealthy Eating ....................................................... 26 Lack of Physical Activity ............................................ 27 Systems of Care
28 Emergency Health Care System (Pre‐hospital care) . 28 The Stroke System of Care ........................................ 29 The Heart System of Care ......................................... 29 Public Health System ................................................. 30 Framework for Action
30 A Model for Action .................................................... 31 Texas Goals, Objectives and Strategies 2013 –
2017 34 Goal 1: Strategies that Support/Reinforce Healthy Behavior .................................................................... 35 Goal 2: Community ‐ Clinical Linkages Enhancements
.................................................................................. 38 6 Executive Summary
Cardiovascular disease (CVD) and stroke are the number one and number three causes of death in Texas.4
However, these chronic diseases are largely preventable through the reduction of modifiable risk factors.
Prevalence, as well as CVD and stroke-related morbidity and mortality rates, can be reduced by: increased
physical activity; good nutrition; tobacco cessation; control of high blood pressure, high blood cholesterol and
diabetes; and reduction of overweight and obesity.
The Texas Plan to Reduce Cardiovascular Disease and Stroke 2013 update (Plan) was developed through
collaboration between the Texas Council on Cardiovascular Disease and Stroke and the Texas Cardiovascular
Disease and Stroke Partnership. It provides a set of goals, objectives, and strategies for reducing morbidity
and mortality related to heart disease and stroke in Texas.
The Plan is modeled after the Coordinated Chronic Disease State Plan Framework and outlines a
comprehensive strategy through four overarching focus areas. The focus areas include Strategies that
Support/Reinforce Healthy Behavior; Community-Clinical Linkages Enhancements; Health Systems
Interventions; and Surveillance and Epidemiology. Each focus area consists of a goal and accompanying
objectives and strategies that tend to be cross-cutting.
Goals of the 2013 Plan include:




Strategies that Support/Reinforce Healthy Behavior: To establish and promote environments that
support the prevention of heart disease and stroke through healthy eating, physical activity, and
tobacco-free lifestyles for all Texans, with an emphasis on access to resources and priority populations.
Community Clinical Linkages Enhancements: To promote partnerships between clinical and
community groups in Texas to provide enhanced and coordinated patient care.
Health Systems Interventions: To promote capacity and infrastructure changes within the health
delivery system to effectively prevent, treat, and manage heart disease and stroke for all Texans.
Surveillance and Epidemiology*: To collect comprehensive heart disease and stroke data that are
readily available to assess, monitor, and describe the burden of heart disease and stroke in Texas.
*Note: Surveillance and epidemiology strategies are included in all Plan objectives to provide data to
monitor progress in priority areas and towards targets.
Thirty sets of objectives, grouped by common desired outcomes, were identified for the Plan. The objectives
reflect Healthy People 2010 and 2020 objectives for improving the health of the nation and are specific to heart
disease and stroke priorities in Texas. The Plan includes objectives that are largely measurable through
existing data sources and are deemed realistic and attainable through coordinated efforts and effective use of
available resources.
The Texas Cardiovascular Disease and Stroke Partnership, the Texas Council on Cardiovascular Disease and
Stroke, and the Cardiovascular Disease and Stroke Program of the Texas Department of State Health
Services will collaborate to implement evidence-based strategies to achieve identified targets by the year 2017.
7 Call to Action
Stakeholders at all levels, including state, regional or community, should be
knowledgeable about CVD and stroke, as well as the diseases’ impact on individuals’
well-being and economic and societal well-being in Texas. We urge you to use this
Plan to determine the role and direction that your organization decides to assume as
part of a unified, coordinated effort to reduce premature death from CVD and stroke, as
well as to improve the quality of life for Texans.
Help empower healthy Texans for a lifetime!
8 Introduction
Cardiovascular disease (CVD) and stroke are the number one and number three causes of death in Texas.4
Together, heart disease and stroke account for nearly three of every ten deaths in the state.4 In addition to the
human consequences, the financial burden of CVD and stroke in Texas is substantial. Hospitalization charges
related to CVD and stroke amounted to nearly $20 billion in 20105, and the following trends suggest this
problem will continue to worsen in the future:

The aging of the population will remain an important factor as older adults reach ages where CVD and
stroke are the most prevalent.

The incidence of morbid obesity in Texas is rising; nearly one in three Texans is obese, and two-thirds
of Texans are overweight.3

Health care, school, and work environments are not keeping pace with the need for healthier food
choices and a community environment conducive to increasing physical activity and access to healthy
food options.

Medical costs associated with CVD and stroke are on the rise due to an increase in per capita health
care spending; total direct health care costs related to CVD are expected to triple by 2030, and direct
health care costs related to stroke are expected to increase by 238 percent over the next 20 years.30
In response to these challenges, the Texas Cardiovascular Disease and Stroke Partnership (Partnership) was
created to work in collaboration with the Texas Council on Cardiovascular Disease and Stroke and the
Cardiovascular Disease and Stroke Program of the Texas Department of State Health Services (DSHS) to
update and implement a statewide plan for addressing CVD and stroke in Texas.
The 2013 Texas Plan to Reduce Cardiovascular Disease and Stroke (Plan) not only reflects a new set of
goals, objectives, and strategies related to improving cardiovascular and brain health in Texas but includes key
implementation activities identified by the Centers for Disease Control and Prevention (CDC) as essential to
implementing a comprehensive public health strategy (see Figure 1):

Communicating Effectively: The Texas public health community should effectively communicate
the urgency and promise of preventing heart disease and stroke and their risk factors through
public information and education utilizing appropriate technology to reach underserved
populations.

Promoting Strategic Leadership: State and local governments, public health agencies, and
community leaders should foster effective leadership and partnerships to prevent heart disease
and stroke by strengthening existing relationships with partners and forging new ones with other
partners.

Taking Action: Community leaders in Texas should take action to promote desirable social and
environmental conditions and promote partnerships to effectively translate current knowledge into
successful outcomes.
9 
Strengthening Capacity: State and local governments, public health agencies, and community
leaders must work to build local and statewide capacity to address the health and wellness of
Texans by expanding partnerships and utilizing resources in a more coordinated and effective way.

Evaluating Impact: Resources should be dedicated to developing new data systems, expanding
and standardizing existing data sources, and effectively monitoring health indicators related to
CVD and stroke to monitor progress made with interventions implemented.

Advancing Policy: Critical policy issues must be addressed, and effective public policy should be
implemented to ensure resources are available, the environment is conducive to the health and
wellness of Texans, and all citizens have access to quality preventive services and treatments.

Promoting Regional and Global Partnerships: State and local governments, public health
agencies, and community leaders in Texas should engage in partnerships to effectively use
resources for optimal outcomes related to cardiovascular health promotion and CVD prevention.1
Effective Communications
Strategic Leadership
Partnerships
Advancing Policy
Taking Action
Strengthening Capacity
Evaluating Impact
Figure 1: Process of Effective Implementation of a Comprehensive Public Health Strategy
Effective implementation of comprehensive public health strategies begins with effective
communications and continues through an iterative process involving strategic leadership, action,
strengthening capacity, evaluating impact, advancing policy, and building partnerships.
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The State of Cardiovascular Disease and Stroke in Texas
Cardiovascular disease (CVD) refers to a group of diseases that targets the heart and blood vessels. It is the
result of complex interactions among a variety of factors including: multiple inherited traits, environmental
factors, diet and exercise, body mass index, blood pressure, cholesterol levels, and tobacco use. Its etiology
suggests that CVD is largely preventable; and, when diagnosed early, disease symptoms and risk factors can
often be mitigated with lifestyle changes and/or treatment with medication. Common forms of CVD include high
blood pressure, coronary heart disease, stroke, and congestive heart failure.
A major cause of CVD is atherosclerosis, a general term describing the thickening and hardening of the
arteries. It is characterized by deposits of fatty substances, cholesterol, and cellular debris on the inner lining of
an artery. The resulting buildup is called plaque, which can partially or completely block a vessel and may lead
to heart attack or stroke. The most prevalent forms of heart disease and stroke are ischemic heart disease and
ischemic stroke. These two forms are caused by narrowed or blocked arteries resulting in reduced blood
supply to the heart or brain. This Plan focuses primarily on these two types of CVD.
According to the American Heart Association (AHA), over 82 million, or one out of every three Americans, have
one or more types of CVD.2 In 2010, about 1.5 million Texas adults ages 18 years and older reported that they
had been diagnosed with heart disease or stroke.3,4
Cardiovascular disease continues to be the number one cause of death in Texas and in the United States
(U.S.).4,6 Over 2,200 Americans die from CVD each day.2 An estimated 30.5 percent of all deaths in Texas in
2010 were due to CVD.4
However, progress has been made. From 2000 to 2010, age-adjusted mortality rates (number of deaths per
100,000 people) due to CVD in Texas and the U.S. steadily declined. The death rate associated with CVD in
Texas declined 30.7 percent during this ten year period. Factors affecting this decline include more effective
medical treatment and an increasing emphasis on controllable risk factors.2, 6
While mortality rates have declined, the financial burden associated with CVD continues to grow. Together,
heart disease and stroke are the number one group of conditions draining health care resources, costing more
than any other diagnostic group. According to the AHA, the estimated direct and indirect costs of CVD in the
U.S. for 2008 was $297.7 billion, and the cost of CVD is projected to triple from 2010 to 2030.2
Diseases of the Heart
In Texas, diseases of the heart claimed over 38,090 lives in 2010.4 Heart disease has been the leading cause
of death in Texas since 1940 and currently accounts for more than one in four (22.9%) deaths. Diseases of the
heart include acute rheumatic fever, chronic rheumatic heart diseases, hypertensive diseases, and ischemic
heart diseases. The Plan focuses primarily on ischemic and hypertensive heart diseases, which account for 73
percent of deaths from heart disease in Texas and much of the financial burden. Hospital charges for ischemic
heart disease in Texas in 2010 exceeded $6 billion.5
The first appearance of heart disease, often presenting as cardiac arrest, can be sudden and devastating, but
cardiac arrest can be reversed if treated within a few minutes. Optimal treatment to restore a normal heartbeat
occurs through electric shock to the heart (defibrillation) within three to five minutes. With every minute that
passes without cardiopulmonary resuscitation (CPR) and defibrillation, the chance of survival is reduced by
seven to 10 percent.7 For this reason, bystander recognition of the signs and symptoms of cardiac arrest and
an immediate call to 911 are critical to improve patient outcomes. In 2009, while 85.9 percent of Texans
11
recognized 911 as the first emergency response option for heart attack and stroke, only 11.8 percent of Texas
adults could correctly identify all signs and symptoms of a heart attack.3
In the event of cardiac arrest, CPR and use of an
automated external defibrillator (AED) should begin
immediately. The availability of AEDs is becoming more
widespread as many municipal and state governments are
instituting mandates for AED programs in public sites such
as schools, shopping malls, and other public places. New
recommendations for CPR performed by bystanders include
high quality chest compressions by pushing hard and fast in
the middle of the chest with minimal interruptions.8
Education to promote the rapid recognition of the signs and
symptoms of cardiac arrest and stroke, calling 911, and
promotion of CPR training and AED availability are a major
focus of public education and training in the 2013 Plan.
What is defibrillation? Most sudden cardiac arrest is caused by ventricular fibrillation (VF), an abnormal heart rhythm. Ventricular fibrillation prevents the heart from pumping blood effectively. Defibrillation is the treatment for VF. Defibrillation delivers an electric shock to the heart that can stop VF and allow the heart to resume a normal rhythm and pump 7 effectively. Stroke
Stroke is the third leading cause of death in Texas and the
fourth leading cause of death in the nation. Over the past
decade, the death rate from stroke in Texas declined by
approximately 32.6 percent (from 66.6 percent in 2000 to 44.9 percent in 2010).2,6 Many more people are
surviving strokes but not without consequences. Stroke can leave a range of disabilities from loss of speech to
paralysis of limbs and other neurological impairments, making stroke a leading cause of long-term disability
and a major economic burden in terms of health care cost and lost productivity.2 The estimated direct and
indirect costs of stroke in the U.S. for 2010 was $53.9 billion.30 Total hospital charges for stroke in Texas in
2010 exceeded $2.7 billion.5
Fortunately, stroke is preventable. When treated immediately, the damage can be minimized. Timely treatment
requires early recognition of signs and symptoms and rapid response. The Behavioral Risk Factor Surveillance
System (BRFSS) survey conducted in Texas in 2009 showed that only 21.1 percent of adults in Texas could
correctly identify all stroke signs and symptoms (see Table 1).3
In addition to early recognition of stroke signs and symptoms by the public, early and appropriate medical
intervention is critical to increase survival and reduce risk of disability. Unfortunately, stroke care in many
communities remains inadequate and fragmented, hindered by lack of expertise and coordination within the
stroke system of care.8 One of the goals in the Plan is to support ongoing efforts to improve systems of care
that target stroke in Texas.
12
Table 1: Recognition of Signs and Symptoms of Stroke in Texas, 2010
% of Respondents who
Recognized Symptoms of Stroke
Symptoms of Stroke
Sudden confusion, trouble speaking or understanding
94.9
Sudden trouble seeing in one or both eyes
87.8
Sudden numbness or weakness of the face, arm or leg
97.2
Sudden trouble walking, dizziness or loss of balance and
coordination
93.5
Sudden severe headache with no known cause
77.4
Recognized all 5 signs and symptoms
21.1
Data source: BRFSS, Center for Health Statistics, TDSHS, 2010
Disparities in Cardiovascular Disease and Stroke
High Risk Populations
Significant disparities exist among Texans with CVD, stroke, or related risk factors. In general, there is a higher
prevalence of CVD and stroke among Texans who are older (especially those ages 65 years and older), earn a
lower income, have received less education, are African American, and have multiple risk factors (see Figures
2 and 3).
Figure 2: Prevalence of CVD by Demographic, Texas Adults, 2010
Data source: BRFSS, Center for Health Statistics, TDSHS, 2010
13
Figure 3: Prevalence of Stroke by Demographic, Texas Adults, 2010
Data source: BRFSS, Center for Health Statistics, TDSHS, 2010
In addition, there is a higher risk of death from CVD and stroke among these at-risk individuals. While CVD and
stroke mortality rates have generally declined for most populations, disparities persist. Between 2006 and
2010, ischemic heart disease mortality rates among Whites, African Americans, and Hispanics showed
significant decline. However, the highest mortality rate from CVD and stroke still occurs in the African American
population, both in Texas and in the U.S. In Texas, the 2010 age-adjusted mortality rate for ischemic heart
disease among African Americans was 132.9 per 100,000 compared to 118.5 per 100,000 for Whites and 94.9
per 100,000 for Hispanics.4
In 2010, the age-adjusted mortality rate for stroke among African Americans was 1.3 times higher than Whites
(60.0 per 100,000 versus 44.7 per 100,000), 1.6 times higher than Hispanics (60.0 per 100,000 versus 38.0
per 100,000), and 1.8 times higher than other ethnic groups (60.0 per 100,000 versus 34.2 per 100,000) in
Texas.4
Geographic differences in mortality rates associated with ischemic heart disease and stroke among Texas
urban, rural, and border regions are attributed to demographic differences. The highest age-adjusted mortality
rates associated with heart disease are concentrated in East and Northeast Texas and the border region. The
highest age-adjusted mortality rates associated with stroke are concentrated in Northeast Texas (see Figures 4
and 5).
14
Figure 4: Age-adjusted Mortality Rates for Ischemic Heart Disease by County, Texas, 2006-2010
15
Figure 5: Age-adjusted Mortality Rate for Stroke by County, Texas, 2006-2010
Access to Care
Barriers to accessing care include, but are not limited to: cost of care; geographic location; lack of insurance;
language barriers; and not having a usual source of primary care. Populations that have decreased access to
care may be referred to as underserved. Among Texans ages 18 years and older who have CVD or stroke in
2010, 14.8 percent stated that they did not have any type of health care coverage; 20.55 percent could not see
a doctor due to the cost; and 26.1 percent did not have a routine checkup within the past year.3
Texas has consistently had a higher rate of health uninsurance compared to the U.S. (see Figure 6).9
Compared to other states, Texas currently ranks lowest for the number of residents who have health
insurance.9 According to Texas BRFSS 2010, Public Health Service Regions along the border and in East
Texas have particularly high rates of uninsurance (see Figure 7). Hispanics (46.2%) and African Americans
(25.3%) are significantly more likely to lack health care coverage than Whites (11.6%). Younger Texas adults
are more likely to be uninsured than older Texans, and Texans with lower education levels and lower annual
income have a greater likelihood of being uninsured (see Figure 8).3
16
Figure 6: Prevalence of No Health Insurance, U.S. and Texas Adults, 2001-2010
Data Source: BRFSS, Center for Health Statistics, TDSHS, 2010
Figure 7: No Health Insurance by Metropolitan Area, Border, Non-border, Texas Adults, 2010
Data source: BRFSS, Center for Health Statistics, TDSHS, 2010
17
Figure 8: Prevalence of No Health Insurance by Demographic, Texas Adults, 2010
Data source: BRFSS, Center for Health Statistics, TDSHS, 2010
Secondary prevention of CVD and stroke relies on the early detection and management of risk factors such as
high blood pressure, high blood cholesterol, diabetes, and obesity. Not having a usual source of primary health
care is a barrier to secondary prevention. In 2010, Texas (38.9%) had significantly higher rates of adults who
had not had a routine health check-up within the past year compared to the national average (31.9%).3
Cost is often a barrier to accessing routine health care, even for those with insurance. Texas (18.8%) had a
significantly higher rate of adults who could not see a doctor in 2010 due to cost compared to the national
average (14.6%). Females had significantly higher prevalence for inability to see a doctor due to cost than
males. Hispanics (29.0%) and African Americans (28.9%) had a higher prevalence for inability to see a doctor
due to cost than Whites (12.0%). Adults in the younger age groups had significantly higher prevalence for
inability to see a doctor due to cost than those over 65 (see Figure 9).3
Access to long term care, including nursing home care, home health care, adult day care, assisted living, and
hospice care is a critical and growing concern for all Americans as the number of elderly people continues to
rise. Victims of both cardiac events and strokes often require post-hospital rehabilitation, and stroke victims left
with disabilities require long term help to perform activities of daily living. Financial barriers and limited
availability of services restrict access to these services. Addressing access to health care for all Texans will
require system-wide policy changes.
18
Figure 9: Prevalence of Could Not See a Doctor Because of Cost, Texas Adults, 2010
Data source: BRFSS, Center for Health Statistics, TDSHS, 2010
Addressing Health Disparities
Addressing disparities in morbidity and mortality from CVD,
stroke, and related risk factors must be a priority for all
stakeholders working in these areas. The 2013 Plan includes a
new objective related to identifying health disparities and at-risk
populations. In addition, new strategies promote culturally
appropriate communication in health care settings, use of nontraditional partners such as community health workers in health
programming and health care settings, and access to
underserved populations. Addressing disparities through the
implementation of culturally competent, evidence-based
strategies that effectively reach priority populations is a focus of
the Plan.
Improving access to care for high risk populations and the underserved should be a priority for all programs working to reach Texans for the prevention, diagnosis, and treatment of CVD and stroke and related risk factors. Risk Factors for Cardiovascular Disease and Stroke
There are several major risk factors that increase a person’s chance of developing CVD. Many of these risk
factors are modifiable through primary prevention measures such as eating a healthy diet, engaging in regular
physical activity, maintaining a healthy weight, and avoiding tobacco use and exposure. Others are modifiable
through secondary prevention measures such as treating and controlling high blood pressure and high
cholesterol, weight loss for overweight and obese individuals, and tobacco cessation for smokers. Though
modifiable, many risk factors for CVD and stroke in Texas have been on the rise over the past decade (see
Figure 10).
19
Figure 10: Prevalence of Risk Factors for CVD and Stroke, Texas Adults, 1999-2010
An examination of the trends in modifiable risk factors over the past decade in Texas demonstrates an increase in the
prevalence of high cholesterol, obesity, diabetes, and high blood pressure. Rates of individuals getting no leisure time
physical activity have remained relatively level. Smoking rates have decreased since 1995, and while data showed an
increase in the estimated number of adults who smoke from 2006 to 2007, a decreasing trend was observed from 2007 to
2010.3
* Data not available for 2010
Data source: BRFSS, Center for Health Statistics, TDSHS, 2010
High Blood Pressure
High blood pressure, also known as hypertension, affects one in three Americans, or more than 76 million
people in the U.S.2 In 2009, about three out of ten (29.1%) Texas adults reported that they had been
diagnosed with high blood pressure.3 Hypertension rates for those ages 65 and older are over 60 percent. As
the population ages, the prevalence of high blood pressure will increase unless broad and effective preventive
measures are implemented.2
In addition to physical consequences, high blood pressure is costly for the nation and the state. The total
annual direct and indirect cost of high blood pressure to the U.S. economy in 2008 was $50.6 billion.2 In Texas
in 2010, hospital charges for high blood pressure exceeded $1 billion.5
High blood pressure can be caused by many different medical conditions, including chronic kidney disease,
primary aldosteronism, renovascular disease, coarctation of the aorta, and thyroid or parathyroid disease;
however, many risks for high blood pressure are modifiable.10 Obesity, excessive alcohol consumption,
smoking, lack of physical activity, and a diet high in sodium are all risk factors for high blood pressure.31
The relationship between blood pressure and the risk for CVD is well established and independent of other risk
factors. High blood pressure is a factor in 69 percent of first-time heart attacks, 77 percent of first-time strokes,
20
and 74 percent of heart failures.2 The higher the blood pressure, the greater the risk for heart attack, heart
failure, and stroke. Blood pressure is classified according to systolic and diastolic readings as normal, prehypertension or hypertension stages one or two (see Table 2).The presence of pre-hypertension signals the
need for increased education and lifestyle changes to prevent the onset of hypertension.10
Table 2: Blood Pressure Classification
Blood Pressure Classification
Blood Pressure Classification
Systolic (mmHg)
Diastolic (mmHg)
Normal
< 120
And < 80
Prehypertension
120-139
Or 80-89
Stage 1 Hypertension
140-159
Or 90-99
Stage 2 Hypertension
> 160
Or > 100
th
Adapted from The 7 Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, DHHS, 2003
Adoption of a healthy lifestyle is critical for the prevention of high blood pressure and is an integral part of the
management of hypertension. Lifestyle changes include weight reduction, adoption of the Dietary Approaches
to Stop Hypertension (DASH) eating plan, sodium reduction, physical activity, smoking cessation, and
moderation of alcohol consumption. Combinations of lifestyle modifications can achieve the best results.10
Unfortunately, in many cases lifestyle modifications alone are not enough to control high blood pressure.
Antihypertensive therapy, frequently with the use of two or more drugs, is often necessary. Antihypertensive
therapy has been associated not only with excellent results in controlling high blood pressure but with
reductions in the incidence of stroke, heart attack, and heart failure. Lifestyle modifications can enhance the
effects of drug therapy and contribute to lower cardiovascular risk.10
However, even the most effective therapy may fail to control hypertension if the patient does not or cannot
adhere to prescribed medication regimens and adopt healthy lifestyle changes. It is important for clinicians to
understand cultural differences, individual beliefs, and socioeconomic barriers to following recommendations
and to use a patient-centered strategy to achieve mutual goals.10 Promoting provider adherence to
hypertension guidelines through provider training and education, in addition to cultural competency training,
may be another key step to increasing high blood pressure control.32
High blood pressure control is a priority in the 2013 Plan and will be a major focus of work in the future for the
Cardiovascular Disease and Stroke Program and the Texas Cardiovascular Disease and Stroke Partnership.
High Blood Cholesterol
About four out of ten (40.9%) Texas adults in 2009 had been diagnosed with high blood cholesterol, a major
risk factor for heart disease.3 Research indicates that elevated low density lipoprotein (LDL) cholesterol, low
high density lipoprotein (HDL) cholesterol, and elevated triglycerides are each independent risk factors for
CVD. 11 Classifications of LDL, HDL, and total cholesterol and triglycerides are outlined in Table 3.
21
Current guidelines from the National Cholesterol Education Program (NCEP) recommend a fasting lipoprotein
profile (total cholesterol, LDL, HDL, and triglyceride) be measured every five years for adults 20 years and
older. Adherence to screening guidelines by health care providers and making patients aware of their
cholesterol levels are critical components of efforts to reduce high cholesterol.11
Table 3: Classification of LDL, Total, HDL Cholesterol and Triglycerides (mg/dL)
Classification of LDL, Total, HDL Cholesterol and Triglycerides (mg/dL)
LDL Cholesterol
Classification
<70
Therapeutic option for very high risk patients
< 100
Optimal
100-129
Near optimal/above optimal
130-159
Borderline high
160-189
High
> 190
Very high
Total Cholesterol
< 200
Desirable
200-239
Borderline high
> 240
High
HDL Cholesterol
< 40
Low
> 60
High
Triglycerides
< 150
Normal
150-199
Borderline high
200-499
High
≥ 500
Very high
Adapted from Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults, 2001 and the 2004 Update
Reducing risk associated with high blood cholesterol involves reducing lifestyle risk factors such as obesity,
physical inactivity, a diet high in saturated fats, excess alcohol consumption, and tobacco use. A diet high in
22
carbohydrates (more than 60 percent of energy intake), certain diseases, certain drugs, and genetic causes
are also associated with abnormal lipoproteins.11
In addition to therapeutic lifestyle changes, treatment with medication therapy may be indicated. LDL lowering
drug therapy has been shown to be very effective in reducing risk for CVD.11 Adherence to NCEP guidelines by
both patients and providers is key to achieving success in managing cholesterol levels and reducing risk for
CVD. The NCEP Expert Panel recommends use of multi-disciplinary methods involving the patient, providers,
and the health care delivery system to achieve population level effectiveness for primary and secondary
prevention of high cholesterol.11 Increasing the proportion of adults who have been screened for high
cholesterol within the past five years and decreasing the proportion of adults with high non-HDL cholesterol
levels are objectives of the 2013 Plan.
Diabetes
Diabetes, a major risk factor for CVD, is a group of diseases marked by high levels of blood glucose and
includes Type 1, Type 2, gestational, and other types resulting from various medical conditions. People with
Type 1 diabetes must monitor and control their blood glucose level through insulin administration. Those with
Type 2 diabetes can often control their blood glucose through diet, exercise, and oral medication.12
It is estimated that nearly 26 million people in the U.S. have diabetes, seven million of whom are still
undiagnosed.12 The prevalence of diabetes in Texas has increased over the past decade from 6.2 percent of
the population in 2000 to 9.7 percent in 2010.3 African Americans (16.5%) have a significantly higher
prevalence of diabetes in Texas, compared to Whites (8.2%) and Hispanics (11%). However, as the Hispanic
population in Texas continues to increase, it is estimated that by 2040, Hispanics will comprise the majority of
diabetes cases.35 Diabetes prevalence also increases significantly with age, increasing sharply at age 45 and
above.
Diabetes negatively affects the risk of cardiac events in addition to cardiac outcomes. Adults with diabetes
have heart disease mortality rates two to four times higher than adults without diabetes, and the risk for stroke
is two to four times greater with diabetes. In fact, two out of three people with diabetes die from heart disease
or stroke. Due to the relationship between diabetes and CVD, diabetes management is complicated and
involves not only control of blood glucose but also of blood pressure and cholesterol levels. Diabetes Selfmanagement Education (DSME) involves providing people with the tools to develop problem-solving and
coping skills to manage diabetes on their own. DSME is integral to good outcomes and a high quality of life.12
The Texas Diabetes Council, established by the Texas Legislature, is charged with developing and
implementing a state plan for diabetes treatment, education, and training. Changing the Course: A Plan to
Prevent and Control Diabetes in Texas, 2012-2013 (Diabetes Plan) identifies five priorities: advancing public
policy; evaluating the impact of diabetes in Texas; promoting comprehensive programs for the prevention of
diabetes; increasing public awareness, promoting community outreach and diabetes education; and improving
diabetes care and prevention of complications by health care professionals. The Diabetes Prevention and
Control Branch of the Texas DSHS undertakes and sponsors a number of key activities that support the five
priorities of the Diabetes Plan.13 An objective of the 2013 Texas Plan to Reduce Cardiovascular Disease and
Stroke is to reduce the death rate from CVD and stroke among those with diabetes.
23
Tobacco Use and Exposure to Second Hand Smoke
Tobacco remains the single most preventable cause of death and disease in the U.S. today. Tobacco use is a
major risk factor for heart disease and stroke.14 From 2000-2004, 32.7 percent of smoking-attributable death
was caused by CVD.33 The CDC estimates that tobacco use costs the country $96 billion in direct medical care
expenses and $97 billion in lost productivity each year.14
In Texas, adult smoking rates decreased significantly from 2007 (19.3%) to 2010 (15.8%).3 The Texas high
school smoking rate in 2011 (high school students who reported smoking cigarettes on one or more days
during the past 30 days) was 17.4% compared to the Healthy People 2010 goal of 16%.15 So while Texas has
seen improvements, there is still progress to be made.
Exposure to secondhand smoke is also causally associated with CVD. According to the CDC, involuntary
exposure to secondhand smoke in home or work environments increases the risk of heart attack by 25-35
percent. Each year in the U.S., 46,000 non-smokers die from CVD related to secondhand smoke.16 Many
Texas communities are working to adopt or have already passed smoke-free ordinances that reduce exposure
to secondhand smoke in public places, including bars and restaurants. However, 57 percent of the municipal
Texas population is still not covered by smoke-free policies across five focal settings, including municipal
worksites, private worksites, restaurants, bars in restaurants, and bars not in restaurants.45
Tobacco-related health disparities are reflected in unequal prevention and treatment of tobacco use,
disproportionate incidence, disparate morbidity and mortality, and inadequate access to resources. Members
of certain racial/ethnic minority groups, people with low socioeconomic status, and people with lower levels of
education are at higher risk for tobacco use and exposure to secondhand smoke and experience more tobacco
related illness and death.34 In Texas, young adults between 18 and 29 (23.6%) had significantly higher
smoking prevalence than older adults (30-44 years, 14.2%; 45-64 years, 17.6%; 65 and older, 8.5%). Males
(18.3%) had higher smoking prevalence than females (13.4%), and Whites (17.0%) and African Americans
(18.3%) had higher smoking prevalence rates than Hispanics (13.7%), although this was not statistically
significant.3
Investments in state level, evidence-based prevention programs have produced significant reductions in
cigarette consumption, demonstrating the need for fully funded statewide tobacco prevention programs at
CDC-recommended levels. Tobacco control in Texas is underfunded with 0.3 percent of the $1.9 billion
collected yearly in Texas from tobacco settlement funds and tobacco taxes invested in comprehensive
community level programs. This spending level places Texas 39th among the states for tobacco prevention
program funding.17
The Texas Cancer Council, which became the Cancer Prevention and Research Institute of Texas (CPRIT) in
2007, is charged with implementing the Texas Cancer Plan and published the Texas Tobacco Control Plan
2008, A Statewide Action Plan for Tobacco Prevention and Control in Texas.34 Partners from across the state
and many community level stakeholders are actively working to reduce tobacco use in Texas. Reducing
tobacco use among youth and adults and reducing exposure to secondhand smoke are objectives of the 2013
Plan.
Overweight and Obesity
The prevalence of overweight and obesity in Texas and the U.S. has been on the rise for the past few
decades. In fact, obesity rates among children have tripled and rates among adults have doubled.18 In 2010,
24
two out of three (66.6%) Texas adults were overweight or obese. Males (73.5%) had a significantly higher
overweight and obesity rate than females (59.2%). Among racial/ethnic groups, Hispanics (74.3%) and African
Americans (73.7%) had significantly higher rates for obesity and overweight compared to Whites (62.9%).
Persons ages 45-64 (72.6%) are significantly more overweight or obese than those ages 18-29 (49.8%) or
older than 65 (65.4%).3
A survey of high school students conducted in 2011 found that 16 percent of students were overweight (at or
above the 85th percentile but less than the 95th percentile for body mass index18), and 19 percent of males and
11.9 percent of females were obese (at or above the 95th percentile for body mass index18). Hispanic students,
followed by African American students, had higher rates of overweight than Whites at 18.4 percent, 17.8
percent, and 12.4 percent respectively.15
Heart disease, stroke, high blood pressure, high cholesterol,
diabetes, cancer, respiratory problems, and arthritis are
among the health consequences of overweight and obesity.
Risk factors for heart disease such as high cholesterol and
high blood pressure are more prevalent in children and
adolescents who are overweight or obese.18
In addition to contributing to poor health outcomes, obesity
harms the economy. According to the CDC, total direct and
indirect medical expenses related to obesity were a
staggering $147 billion in 2008.19 The Texas Comptroller
estimates that obesity cost Texas businesses $9.5 billion in
2009, and if obesity rates among the Texas workforce
continue to increase, obesity could cost Texas businesses
$32.5 billion in 2030.39
Overweight and obesity classifications are determined by body mass index (BMI), a ratio of body weight (kg) to height (m) 2. Overweight is defined, in adults, as a BMI between 25 and 29.9. Obesity in adults is defined as a BMI of 30 or higher. In children, overweight is defined as between the 85th and 95th percentile for BMI for age and sex specific percentile, and obesity is defined as 95th percentile and higher. 18 The Surgeon General’s Vision for a Healthy and Fit Nation identifies, as a national priority for immediate action,
the need for the nation to take an informed, sensitive approach to communicate with and educate the American
people about health issues related to overweight and obesity. While personal behaviors and choices related to
diet and physical activity do affect health outcomes including obesity, focus on changing the social and
physical environments allows individuals and communities to have opportunities to make healthy choices that
lead to positive health outcomes.18
Research has shown that childhood obesity, even among underserved populations, can be reduced by finding
and using opportunities for comprehensive obesity prevention and control efforts that involve community
programing, school health programs, nutrition and physical activity programs for adults, and advertising
campaigns.44 The Nutrition, Physical Activity, and Obesity Prevention Program at DSHS has worked with
partners from across the state to produce Updates for the Strategic Plan for the Prevention of Obesity in Texas
2008 (Update). The Update is intended to provide direction and focus as Texans move forward with
implementation of the Strategic Plan for the Prevention of Obesity in Texas: 2005-2010 (Obesity Plan). The
Update identifies 19 key targets from the Obesity Plan and 55 indicators that will be used to track progress as
partners across Texas work to address obesity as a public health issue; create opportunities to choose
lifestyles that promote healthy weight; implement policies and environmental changes that support healthful
eating and physical activity; and decrease obesity rates through the dissemination of evidence-based
25
practices.20 Reducing the proportion of adults and youth who are overweight or obese is an objective of the
Texas Plan to Reduce Cardiovascular Disease and Stroke.
Unhealthy Eating
Nutrition plays an important role in an individual’s overall health and quality of life. A diet high in calories,
saturated or trans fats, cholesterol, sodium, and/or sugar contributes to poor health. Whereas a diet high in
fruits and vegetables leads to better health outcomes.21
For reducing risk of CVD and stroke, the American Heart
Association encourages individuals to know their daily caloric
intake to ensure calories eaten do not exceed calories burned
through daily physical activity and consuming nutrient rich foods
that are high in vitamins, minerals, fiber, and other nutrients but
low in calories.21
Americans are encouraged to eat a variety of foods, including:
A NOTE ON BREASTFEEDING Breastfeeding benefits extend into adulthood, and have shown positive outcomes for mothers and infants, in addition to children and adults who were breastfed as infants. 
Vegetables and fruits (at least 4.5 cups a day)

Unrefined whole grains

Low fat dairy products, lean meats, poultry, and fish, hyperlipidemia later in life and were less likely including oily fish high in omega-3 fatty acids
to develop cardiovascular disease later in 
Limited amounts of salt, sugar, saturated fats, trans
fats, and cholesterol 21
The 2013 Plan focuses on three of the Healthy People 2020
objectives for improving nutrition related to CVD and stroke: fruit
and vegetable consumption and sodium intake.
Studies have shown that women who breastfed for 7‐12 months were less likely to have hypertension, diabetes, and life.22 Breastfeeding also has been associated with higher levels of HDL‐c and lower BMI in adulthood.42 Studies have shown that children who were not breastfed experience higher average blood pressure and cholesterol, and adults who were not breastfed as infants have In 2009, Texas (76.2%) had a similar prevalence of eating fruits significantly higher average cholesterol levels and vegetables fewer than five times per day compared to the
than their breastfed counterparts. 43 nation (76.3%). Males (80.8%) had a significantly higher
prevalence of low fruit and vegetable consumption than females
(71.8%), and there was no statistically significant difference
among racial/ethnic groups.3 Poor eating habits are often established during childhood, so resources should be
directed toward initiatives that affect children’s nutrition. Only 18.5 percent of Texas high school students in
2011 reported eating five or more servings of fruits and vegetables per day. African American (21.0%) and
Hispanic (20.2%) students were more likely to report they had eaten five or more servings of fruits and
vegetables per day for the past seven days than White students (14.8%), but the difference was not statistically
significant. Male high school students (21.2%) were significantly more likely to report they had eaten five or
more servings of fruits and vegetables per day for the past seven days than female high school students
(15.6%).15
Dietary sodium reduction is a cornerstone in managing high blood pressure. Excessive sodium intake is a
proven risk factor for high blood pressure, which can lead to cardiovascular events .23 The 2010 Dietary
Guidelines for Americans recommends reducing sodium intake to no more than 2,300 mg per day for the
26
general population and no more than 1,500 mg per day for those who are at a higher risk for cardiovascular
events.23 A popular, evidence-based approach to reducing hypertension is the Dietary Approaches to Stop
Hypertension (DASH) eating plan. A 1,600 mg sodium DASH eating plan has effects similar to single drug
therapy for treating high blood pressure.10 Reducing the amount of sodium in manufactured/packaged and
restaurant-prepared foods has become a national initiative to reduce daily intake of sodium by Americans.23
To meet national and state objectives for good nutrition, the CDC recommends a public health approach that
includes continued surveillance and strategies that support and reinforce healthy behavior and address
barriers. Interventions that increase public awareness, effectively motivate individual behavior change, and
increase access to affordable healthy foods should be promoted. Related strategies include health care
provider recommendations, school-based initiatives, faith-based and culturally appropriate programs, and
access to community gardens and farmer’s markets.24 Objectives to increase the proportion of youth and adults
who report eating fruits and vegetables five or more times per day and who report currently taking measures to
reduce sodium intake are a focus of the 2013 Plan.
Lack of Physical Activity
Regular physical activity is associated with reduced risk for chronic disease and a healthier, longer life.
Cardiovascular benefits of regular physical activity include lower risk for heart disease, high blood pressure,
stroke, abnormal blood cholesterol and triglycerides, diabetes, and obesity.25
Despite the benefits, most Texans, like most Americans, are sedentary. In 2010, the proportion of Texas adults
who reported no participation in leisure time activity (26.7%) was significantly higher than the national average
(24.4%). Females (29.9%) were significantly less likely to participate in leisure time activity compared to males
(23.4%). African Americans (32.6%) and Hispanics (32.3%) had a significantly higher prevalence of no leisure
time activity than Whites (23.0%). Persons over the age of 65 (32.9%) were significantly less likely to
participate in leisure time activity than other age groups.3
Lack of physical activity has contributed to a sharp increase in childhood obesity over the past 20 years.18 In
2011, too few Texas high school students reported being physically active for at least 60 minutes per day on
five or more days during the past week (44.5%). Males were significantly more likely to be active (53.6%) than
females (35.1%), while Hispanic students were less likely to be active (39.6%) compared to Whites (50.4%)
and African Americans (47.8%).15
The U.S. Department of Health and Human Services recommends that adults do 150 minutes of moderately
intense exercise per week or 75 minutes of vigorous exercise. Youth recommendations are 60 minutes daily of
moderately intense to vigorous activity. Adults should also engage in muscle-strengthening exercise two or
more days per week for additional health benefits.25 Only 48.1 percent of Texans 18 and older participated in
moderate physical activity in 2009.3 Children and adolescents should have at least 60 minutes of moderate
physical activity a day, with at least three days a week of vigorous physical activity. Children and adolescents
should also do physical activity that involves muscle-strengthening and bone-strengthening at least three days
of the week.25
Interventions that have shown success in promoting physical fitness include: limiting screen time for youth,
establishing policies for physical activity in child care and school settings; creating physical activity curricula
based on national standards; establishing worksite wellness programs that promote physical activity by offering
incentives, designated exercise areas, safe walking paths and stairwell programs; supporting health care
provider reminders related to physical activity screening and education; building infrastructure for safe walking
27
and biking in the community; and improving access to public transportation.18 The 2013 Plan includes
objectives to increase the proportion of adults and youth who engage in regular physical activity.
Systems of Care
The early detection and effective treatment of already-established CVD is crucial. Monitoring, tracking, and
making improvements, where needed, within the systems of care in Texas are priorities in the 2013 Plan.
Information and data regarding the general public’s knowledge of early warning signs and symptoms of heart
attack and stroke events, the development and implementation of screening and treatment guidelines and
protocols, and the quality and equity of long term care are needed in order for Texas policy makers, agency
and organizational leaders, and community level practitioners to better understand the issues and challenges
Texas faces in reducing mortality and morbidity from heart attack and stroke.
The benefits of rapid identification and treatment of heart attack and stroke are clear. Early treatment of heart
attack reduces heart muscle damage and early treatment of stroke can minimize functional disability. As
therapies become increasingly more effective, rapid implementation of therapies has become critical to
improving patient outcomes.37 Strategies for improving patient outcomes include developing and implementing
clinical practice guidelines and protocols that reflect accepted standards of care and providing education and
training for emergency department personnel.
The systems of care targeting cardiac and stroke events can be classified as the emergency health care
system or pre-hospital care; the stroke system of care; the heart system of care; and the public health system.
While each of these systems has a unique role, coordination among the systems of care is of utmost
importance to ensure efficient and effective, high-quality care.
Emergency Health Care System (Pre-hospital care)
For both a stroke event and a cardiac event, rapid diagnosis and treatment can mean the difference between
recovery, disability, or death. Healthy People 2020 has set developmental objectives for increasing the
proportion of persons who have access to rapidly responding pre-hospital emergency services and the
proportion covered by basic life support or advanced life support.36
In Texas, the average Emergency Medical Services (EMS) response time for a suspected cardiac event in
2008 was approximately 8.5 minutes from the time the call was received to the time EMS arrived on the scene,
and the average delivery time was nearly 39.7 minutes from the time the call was received to the time EMS
arrived at the destination, generally a hospital. For a suspected stroke, the average EMS response time was
approximately 11.0 minutes and the average delivery time was 42.3 minutes.37
Response times varied across Public Health Service Regions (HSR). Some Regions demonstrated
improvement in response time between 2007 and 2008 while others did not. The average EMS response times
for cardiac arrest in HSR 11 increased from 7.6 minutes in 2006 to 13.4 minutes in 2008, and the average
EMS response time for stroke increased from 8.8 minutes in 2006 to 27.7 minutes in 2008. 37 (Note: These
numbers are likely underestimations as the Texas EMS/Trauma Registry did not receive medical-related calls
from all participating EMS providers in Texas.37)
A 2010 survey conducted of EMS in 200 cities in America identifies the need for improvements in the
emergency health care system from the time a 911 call is placed until the patient is delivered to the hospital.
28
Other identified issues within the emergency system of care include service cutbacks related to decreased tax
funding and an increasing number of uninsured patients; use of emergency medical dispatch protocols; use of
electronic patient care records; use of transport protocols for designated cardiac or stroke centers; lack of
protocols for use of thrombolytics; and community CPR and public access defibrillator programs.26 The
emergency health care system, in coordination with the stroke, cardiac, and public health systems of care, will
need to address these current issues moving forward to provide high-quality, efficient care.
The Stroke System of Care
Many areas of Texas are currently underserved with regard to stroke facilities that are able to effectively
diagnose, treat, and manage stroke patients. DSHS designates Texas stroke facilities as either
comprehensive, primary or support facilities, based on services provided. Services may include acute stroke
care, supportive care and transport, and comprehensive stroke care including the full range of stroke
treatments, rehabilitation, and long term care.
The Cardiovascular Disease and Stroke Program and Texas Cardiovascular Disease and Stroke Partnership,
in consultation with the DSHS Office of EMS and in collaboration with the American Heart Association (AHA)
and the American Stroke Association (ASA), developed the Stroke Public Education Toolkit -2010. This
initiative aimed to impact timely care to patients, reduce the burden of stroke, and improve survival outcomes
through public education campaigns (see Appendix I). Continuing to improve and expand the stroke system of
care in Texas is a focus of the 2013 Plan.
The Heart System of Care
The heart system of care ranges
STEMI vs. NSTEMI from acute care to rehabilitation
services. Many areas of Texas also
ST‐elevation myocardial infarction (STEMI) is a heart attack that are underserved with regard to
such capacity for cardiac care,
happens as a result of total coronary artery blockage. Because of the even though early treatment and
occlusive nature, there is a high risk of death and disability with STEMI. continued management is crucial.
A non ST‐elevation myocardial infarction (NSTEMI) may occur when an Patients who receive artery
artery is partially blocked and therefore severely reducing blood flow opening therapy within the first or
second hour after the onset of
through that artery. The fastest way to differentiate a STEMI and heart attack symptoms experience
NSTEMI event is through an electrocardiogram (ECG). 28 significant reductions in disability
and death.37 An AHA initiative for
ST elevation myocardial infarctions
(STEMI), called Mission: Lifeline, focuses on increasing the number of patients with timely access to quality
care. According to the AHA, about 250,000 people a year experience STEMI. About 30 percent of those
people do not receive percutaneous coronary intervention (PCI) or thrombolytic therapy, and of those who do
receive PCI, only 40 percent receive PCI within the timeframe recommended by AHA. Less than 50 percent of
patients receive thrombolytic therapy within the recommended timeframe, and 70 percent of patients who are
not eligible for thrombolytic therapy do not receive PCI, which is the only other option to restore blood flow to
occluded arteries.28
29
In addition to STEMI events, guidelines for treating non ST-elevation myocardial infarction (NSTEMI), are not
routinely followed in all patients, and therefore NSTEMI outcomes are not as positive as they should be based
on current scientific knowledge.38 Therefore, appropriate utilization of treatment for cardiovascular events and
improving and expanding the heart system of care in Texas is a key objective of the 2013 Plan.
Public Health System
Throughout its history, DSHS has funded and supported numerous statewide and community level initiatives to
reduce CVD and stroke. DSHS continues to address CVD and stroke as a public health issue through the
CDC-funded Cardiovascular Disease and Stroke Program. In addition, the program supports the Texas
Council on Cardiovascular Disease and Stroke and the Texas Cardiovascular Disease and Stroke Partnership.
A systems approach that focuses on building capacity for state and local efforts to implement population-based
interventions has been and will continue to be a priority for the Cardiovascular Disease and Stroke Program.
The Cardiovascular Disease and Stroke Program and statewide Partnership are pursuing population-based,
capacity-building strategies, including: monitoring CVD and stroke; supporting collaboration among partners;
coordinating available services and resources; expanding reach and improving quality of care; connecting
partners to evidence-based interventions; and working to reduce health care disparities. The 2013 Plan
includes objectives related to those efforts and aims to increase the capacity for state and local entities to
implement the Plan.
Framework for Action
The Texas Framework for Heart Disease and Stroke (Framework) has undergone a dramatic change since
2008. The new Framework is modeled after the Coordinated Chronic Disease State Plan Framework and
outlines a comprehensive strategy for the Texas Plan to Reduce Cardiovascular Disease and Stroke through
four domains or focus areas (see Figure 11). Domains include Strategies that Reinforce/Support Healthy
Behavior, Health Systems Interventions, Community-Clinical Linkages Enhancements, and Surveillance and
Epidemiology. Each focus area contains a goal and accompanying objectives and strategies that tend to be
cross-cutting with many similar aims. The Strategies that Support/Reinforce Healthy Behavior focus area
contains policy or environmental approaches to achieving health behavior changes. The Clinical-Community
Linkages Enhancements focus area contains strategies that promote partnerships between clinical groups and
community supports to improve patient health. The Health Systems Interventions focus area contains
strategies that aim to improve the way health care systems in the state detect, manage and control heart
disease and stroke through changes in capacity and infrastructure. Lastly, the Surveillance and Epidemiology
domain comprises objectives and strategies that aim to provide enhanced data and information for purposes of
monitoring trends and progress, raising awareness, increasing knowledge, and ultimately decision-making. In
an effort to move towards a more coordinated approach to CVD and stroke , as well as to chronic disease, the
2013 objectives and strategies tend to be cross-cutting through the four focus areas.
The Framework also demonstrates which sectors, partners, and organizational resources frame the Plan.
Identified sectors include worksites, schools, communities, and health care settings. Inputs include the Texas
Council on Cardiovascular Disease and Stroke, the Texas Cardiovascular Disease and Stroke Partnership, the
Cardiovascular Disease and Stroke Program, and national and state partners. Organizational resources
include the Texas Department of State Health Services, the Health Promotion & Chronic Disease Prevention
Section, and the Division for Preparedness and Disease Control.
30
As the framework suggests, when four broad approaches (Strategies that Support/Reinforce Healthy Behavior,
Health Systems Interventions, Clinical-Community Linkages Enhancements and Epidemiology and
Surveillance) are fully and effectively implemented, a heart healthy, stroke-free Texas can be realized.
A Model for Action
In addition to a framework, a logic model is a tool for graphically representing the relationships between a
program’s activities and its intended effects, the assumptions that underlie expectations, and the context in
which the program will operate.29 Figure 12 depicts a logic model that represents the critical entities that are
needed for successful Plan implementation; major activities that will take place, especially those involving the
coordinated efforts of the Partnership; concrete outputs that will be generated along the way; and expected
short, intermediate, and long term outcomes.
31
Figure 11: Framework for a State Plan to Reduce Heart Disease and Stroke
32
Figure 12: Logic Model
33
Texas Goals, Objectives and Strategies 2013 – 2017
The Texas Plan to Reduce Cardiovascular Disease and Stroke (Plan)
identifies a set of goals and objectives, and proposes evidence-based,
best practice, or promising strategies to approach these objectives.
Some strategies are cross-cutting, and so address more than one
objective. When objectives apply to multiple focus areas, they are
listed within a primary focus area and the additional applicable focus
areas are denoted with an asterisk. Many of the objectives are taken
directly from the national Healthy People (HP) 2010 and 2020
objectives for improving the health of the nation. Progress in meeting
these objectives can be measured using established health indicators
and existing data collection sources.
Goal: A statement of a long term expected outcome. Objective: A short‐term, measurable change that, when accomplished, will help
in reaching the goal. Strategy: A relatively broad approach to achieving an objective. In some cases, the objectives are related to improving the systems of
care in Texas and building capacity for local and statewide
cardiovascular and brain health efforts. These objectives are not
measurable using established health indicators and therefore are
labeled as “developmental.” Stakeholders taking action in these areas
should identify indicators for monitoring and reporting success early
on.
SMART Objectives should be Specific, Measurable, Attainable, Realistic and Time‐bound. For many strategies, there may be specific evidence-based or best practice programs or interventions already
in existence. See Appendix I for a list of existing, evidence-based or promising programs/resources.
Stakeholders should seek and use existing, evidence-based programs when they exist and, when they do not,
should develop new interventions using theory based approaches and good evaluation techniques.
Stakeholders in Texas working on cardiovascular and brain health should be able to identify where their efforts
fit within this Plan. Individuals and organizations will determine how their mission plays a part in implementing
the Plan and will identify what actions they are taking or will take in the future to implement identified
strategies. Partners’ action planning around strategy implementation will serve to further efforts toward
achieving short-term objectives and long-term goals. Working together, stakeholders in Texas can achieve
progress in reaching these goals and, ultimately, in reducing premature death and improving quality of life for
Texans with heart disease and stroke.
34
Key to Symbols
Objectives also have SS but not in key
SE: The strategy is supported with Strong Evidence and recommended by the Guide to
Community Preventive Services or the U.S. Preventive Services Task Force
SE-Other – Supported with Strong Evidence by the indicated agency
EUR: The Evidence to support the effectiveness of the strategy is currently Under
Review (as of June 2008)
R: The strategy is Recommended by the Guide to Community Preventive Services, the
U.S. Preventive Services Task Force, or the CDC
Goal 1: Strategies that Support/Reinforce Healthy Behavior
To establish and promote environments that support the prevention of heart disease and stroke
through healthy eating, daily physical activity, and tobacco-free lifestyles for all Texans, with an
emphasis on access to resources and priority populations.
Objective 1.1: By June 30, 2017 increase the proportion of adults who engage regularly in moderate
physical activity for at least 150 minutes per week by 5% (HP 2020)
Objective 1.1.1: By June 30, 2017, reduce the proportion of adults who engage in no leisure-time
physical activity by 5% (HP 2020)
Implement community-wide campaigns (SE)
Promote worksite physical activity programs (SE)
Create/enhance access to places for physical activity such as parks, trails, bike lanes, and sidewalks combined
with information outreach (SE)
Objective 1.2: By June 30, 2017, increase the proportion of youth grades 9-12 who have been
physically active for a total of 60 minutes per day on five or more days per week by 5% (HP 2020)
Encourage school-based physical education, define physical education requirements for schools, and educate
about existing policy concerning physical education requirements (SE)
Improve/implement community wide campaigns (SE)
35
Develop collaborations among community partners working to increase youth physical activity levels (nonfamily social support) (SE)
Objective 1.3: By June 30, 2017, increase the proportion of adults 18 and older who report eating fruits
and vegetables five or more times per day by 5% (HP 2010)
Objective 1.3.1: By June 30, 2017, increase the proportion of youth grades 9-12 who report eating fruits
and vegetables five or more times per day by 5% (HP 2010)
Enhance access to healthy foods (R - National Prevention Council) and reduce access to unhealthy foods at
worksites and in community and school-based settings (SS)
Provide information about produce that includes price and easy preparation ideas (SS)
Encourage eligible youth to participate in the National School Lunch Program (SE - USDA)
Implement recognition programs for schools meeting standards (R - U.S. Department of Agriculture)
Objective 1.4: By June 30, 2017, reduce the proportion of adults who report a BMI (height and weight
self-report) equal to or greater than 25 Kg/m2 by 5% (HP 2020)
Objective 1.4.1: By June 30, 2017, reduce the proportion of youth grades 9-12 who report a BMI (height
and weight self-report) equal to or greater than the sex and age specific 95th percentile from CDC
growth charts by 5% (HP 2020)
Implement multi-component interventions aimed at diet, physical activity, and cognitive change at worksites
and in other settings (R)
Research evidence-based programs for maintaining healthy BMI in college-age adults (SS)
Implement community interventions that increase access to affordable healthy foods and places to be
physically active (SE)
Educate about physical education curricula in schools (SE)
Expand coordinated school health requirements through grade 12 (R)
Educate about the benefits of existing and enhanced physical activity, nutrition, and coordinated school health
strategies for all grades (SS)
Objective 1.5: By June 30, 2017, reduce the proportion of youth grades 9-12 who report ever using any
type of tobacco on one or more days by 10% (HP 2020)
Objective 1.5.1: By June 30, 2017, reduce the proportion of youth grades 9-12, who report using
cigarettes in the past 30 days by 10% (HP 2020)
Objective 1.5.2: By June 30, 2017, reduce the proportion of youth grades 9-12 who report using
smokeless tobacco products in the past 30 days by 10% (HP 2020)
Objective 1.5.3: By June 30, 2017, reduce the proportion of youth grades 9-12 who report using cigars
in the past 30 days by 5% (HP 2020)
36
Educate about the use of evidence-based tobacco programs that include educational, clinical, and social
strategies with the goal of tobacco and smoke-free environments (SE)
Use peer-involved campaigns (SS)
Implement multi-component campaigns that include use of mass media, school and community prevention
campaigns, and tobacco and smoke-free environments (SE)
Educate about ordinances that prohibit sale of tobacco to minors (SE)
Provide health care provider counseling (SE)
Objective 1.6: By June 30, 2017, reduce the proportion of adults who smoke cigarettes by 10% (HP
2020) *Also Health Systems Interventions
Objective 1.6.1: By June 30, 2017, reduce the proportion of adults who use smokeless tobacco
products by 5% (HP 2020)
Objective 1.6.2: By June 30, 2017, reduce the proportion of adults who smoke cigars (Developmental)
(HP 2020)
Promote health care provider screening and counseling (SE)
Promote counseling among pediatricians to promote cessation and prevention efforts in pregnant women and
mothers (SE)
Implement multi-component campaigns that include use of mass media, education, school and community
prevention campaigns, and tobacco cessation (SE)
Educate about smoke-free environments in public places, including worksites (SE)
Support interventions that increase the unit price for tobacco products (SE)
Objective 1.7: By June 30, 2017, reduce exposure to secondhand smoke by 5% (HP 2020) *Also Health
Systems Interventions
Educate about community policies for smoke-free public spaces, including worksites (SE)
Educate about existing tobacco and smoke- free environments (SE)
Develop grass roots coalitions to work on smoke-free environments (R)
Promote counseling among pediatricians to promote cessation and prevention efforts in pregnant women and
mothers (SE)
Encourage state hospital licensure requirements to require smoke-free campuses (SS)
Promote smoke-free school requirements (R)
Objective 1.8: By June 30, 2017, increase proportion of Texans who report currently taking measures
to reduce sodium intake (Developmental)
37
Educate about procurement practices that limit sodium in government purchased food, worksites, and schools
(SE - Institute of Medicine)
Promote availability of lower sodium food options (fresh produce) (R)
Promote expansion of consumer information and labeling initiatives for sodium (e.g., point of purchase warning
labels) (SE - Institute of Medicine)
Collaborate with business coalitions to promote healthy workplace programs and environments that help lower
sodium intake (R)
Collaborate with food manufacturers, restaurant associations, and schools to promote sodium reduction (SEInstitute of Medicine)
Promote the Dietary Approaches to Stop Hypertension eating plan (DASH) (SE - U.S. Department of Health
and Human Services)
Objective 1.9: By June 30, 2017, reduce the proportion of adults 18 and older with high blood pressure
by 5% (HP 2020)
Increase the number of worksites that have physical activity and nutrition programs or best practice wellness
programs, strategies, and environmental supports that reduce risk factors related to high blood pressure (SE)
Implement community level programs promoting healthy eating, physical activity, smoking cessation, and
healthy weight (SS)
Work to decrease sodium content in restaurant and manufactured foods (SS)
Goal 2: Community - Clinical Linkages Enhancements
To promote partnerships between clinical and community groups in Texas to provide enhanced and
coordinated patient care.
Objective 2.1: By June 30, 2017, increase the proportion of persons at risk for or with cardiovascular
disease who are aware of resources regarding disease management (Developmental)
Continue to enhance web-based resources that promote evidence-based material for patients (R), including
the Texas Cardiovascular Disease and Stroke Partnership web-site
Partner with health promotion experts to develop culturally appropriate communication (SS)
Work through community networks to share information and resources (R)
Objective 2.2: By June 30, 2017, collaborate with the Governor’s EMS and Trauma Advisory Council
(GETAC) to increase resources available to advance prevention efforts and improve the Texas heart
and stroke system of care (Developmental)
Increase collaboration and create synergy, and leverage existing resources among Texas stakeholders (R)
Use existing data to educate stakeholders about issues (R)
38
Continue to advance the power and commitment of the Texas Cardiovascular Disease and Stroke Partnership
to impact change in Texas (R)
Objective 2.3: By June 30, 2017, increase access to cardiovascular disease and stroke prevention,
early detection, and treatment services for underserved populations (Developmental)
Objective 2.3.1: By June 30, 2017, increase access to cardiovascular disease and stroke prevention,
early detection, and treatment services for rural populations (Developmental)
Objective 2.3.2: By June 30, 2017, increase access to cardiovascular disease and stroke prevention,
early detection, and treatment services for populations in poverty (Developmental)
Objective 2.3.3: By June 30, 2017, increase access to cardiovascular disease and stroke prevention,
early detection, and treatment services for the uninsured population (Developmental)
Expand the cardiovascular health care system to include non-traditional partners that can assist in improving
access to care (R)
Promote the use of community health workers (R)
Promote appropriate cultural competency trainings for the health care work force (R - AHRQ)
Promote the creation of new community health centers and expanded services at existing community health
care centers (R - U.S. Department of Health and Human Services)
Objective 2.4: By June 30, 2017, increase the proportion of adults who are aware of the early warning
signs and symptoms of heart attack and stroke and the importance of calling 911 if a heart attack or
stroke is suspected by 10% (HP 2020)
Promote the use of evidence-based public education programs tailored to appropriate audiences (R)
Partner with Emergency Medical Services, 911 authorities, state agencies, and non-profits to serve as conduits
for information dissemination (R)
Promote media campaigns to increase knowledge of early warning signs of heart attack and stroke and how to
respond (SS)
Objective 2.5: By June 30, 2017, increase the proportion of out-of-hospital cardiac arrests in which
appropriate bystander and emergency medical services were administered (Developmental) (HP 2020)
Provide community based group training in CPR and the use of AEDs (SS)
Support the establishment of evidence-based, CPR/AED programs in schools (R - American Heart
Association)
Promote AED placement policies for businesses, restaurants, and other community settings (R -American
Heart Association)
Objective 2.6: By June 30, 2017, increase the proportion of adults who are taking at least two
preventive actions (for example: changing eating habits, exercising, reducing sodium intake, taking
39
medications) who are at risk for or who have cardiovascular disease, including stroke by 5% *Also
Health Systems Interventions
Implement community outreach and worksite programs promoting healthy eating (for example the DASH
eating plan), physical activity, smoking cessation, and healthy weight (SS)
Identify, disseminate, and promote utilization of evidence-based guidelines for hypertension diagnosis,
treatment, and management (R)
Promote the availability of health plans that cover/include appropriate screenings and incentives to identify,
reduce, and treat high blood pressure (SS)
Encourage health care practices to use team-based care that includes a multidisciplinary team of health care
professionals (SS)
Promote health care system level solutions that use practitioner and patient reminders and medical records
flags (R)
Work with third party payers to reimburse for high blood pressure management (SS)
Increase access to primary health care and affordable medications for underserved populations (R)
Assess and address barriers to compliance with physician recommendations and prescribed medications (R)
Objective 2.7: By June 30, 2017, increase the number of Heart and Stroke Healthy communities in
Texas from 31 to 34 *Also Health Systems Interventions and Strategies that Support/Reinforce Healthy
Behavior
Promote the implementation and monitoring, by Texas cities, of Heart and Stroke Healthy City (HSHC)
Recognition Program indicators (R)
Increase connections between regional or local advisory groups or partnerships and regional resources to
promote sharing of resources and improving initiatives related to cardiovascular disease and stroke prevention
(SS)
Expand collaboration and connectivity among health related organizations (SS)
Objective 2.8: By June 30, 2017, increase communication and collaboration between system partners,
including the Department of State Health Services, and Texas communities. (Developmental) *Also
Strategies that Support/Reinforce Healthy Behavior
Continue to advance the commitment of the Texas Cardiovascular Disease and Stroke Partnership to impact
change in Texas (SS)
Explore the use of web casts to share progress and emerging information (SS)
Support the Texas Cardiovascular Disease and Stroke Partnership to spearhead stakeholder education about
heart disease and stroke and education about policies and plans that support cardiovascular health and
wellness (SS)
40
Goal 3: Health Systems Interventions
To promote capacity and infrastructure changes within the health delivery system to effectively
prevent, treat, and manage heart disease and stroke for all Texans.
Objective 3.1: By June 30, 2017, increase the proportion of adults with high blood pressure whose
blood pressure is under control (< 140/90) by 5% (HP 2020)
Promote implementation of screening guidelines by health care professionals for the early detection and
treatment of high blood pressure (SE)
Promote the availability of health plans that cover/include appropriate screenings and incentives to identify,
reduce, and treat high blood pressure (SS)
Encourage health care practices to use team-based care that includes a multidisciplinary team of health care
professionals (SS)
Promote health care system level solutions that use practitioner and patient reminders and medical records
flags (R)
Work with third party payers to reimburse for high blood pressure self-management training (SS)
Increase access to primary health care and affordable medications for underserved populations (R)
Promote Chronic Disease Self-Management Training for health care providers (R)
Promote the use of community health workers in treating patients with high blood pressure (R)
Promote team-based care for improving blood pressure control (SE)
Objective 3.2: By June 30, 2017, reduce the death rate from cardiovascular disease and stroke in
persons with diabetes by 10% (HP 2020) *Also Community Clinical Linkages Enhancements
Promote partnerships with the Diabetes and Coordinated Chronic Disease programs (R)
Promote risk reduction for cardiovascular disease and stroke in persons with diabetes (R)
Promote the use of clinical practice guidelines and an integrated approach for managing persons with diabetes
to reduce risk for cardiovascular disease and stroke (R)
Improve access to care for underserved populations (R)
Encourage third party payers to cover chronic disease self-management (SS)
Promote Chronic Disease Self-Management Training for health care providers (R)
Promote the use of community health workers in treating patients with high blood pressure (R)
Promote team-based care for improving blood pressure control (SE)
Objective 3.3: By June 30, 2017, increase the proportion of adults who have high blood pressure who
take aspirin, as advised by a health care professional, to reduce the chance of a heart attack and/or
stroke (Developmental) (HP 2020)
41
Promote provider adherence to recognized prevention guidelines regarding the use of aspirin therapy (R)
Encourage utilization of electronic health records and flags for providers (SS)
Objective 3.4: By June 30, 2017, increase the proportion of adults who have had their blood cholesterol
screened within the preceding five years by 5% (HP 2020) *Also Strategies that Support/Reinforce
Healthy Behavior
Promote implementation of screening guidelines by health care professionals for the early detection and
treatment of lipid disorders (R)
Include screening for total lipid panel in worksite wellness programs (R)
Encourage provision of incentives for routine physical exams that include cholesterol screening (SS)
Objective 3.5: By June 30, 2017, reduce the proportion of adults with high blood cholesterol levels by
5% (HP 2020) *Also Strategies that Support/Reinforce Healthy Behavior
Objective 3.5.1: By June 30, 2017, reduce the proportion of adults with high non-HDL blood cholesterol
levels (Developmental)
Implement community outreach programs promoting healthy eating and physical activity (SE)
Promote the availability of health plans that cover/include appropriate screenings and incentives to identify,
reduce and treat lipid disorders (SS)
Increase the number of worksites that have evidence-based wellness programs, policies, and environmental
supports that contribute to the reduction of high cholesterol and other risk factors related to heart disease and
stroke (SS)
Objective 3.6: By June 30, 2017, increase the proportion of adults 18-75 who had an LDL-c level of less
than 100mg/dL during the measurement year, after discharge for an acute cardiovascular event by 15%
*Also Community Clinical Linkages Enhancements
Emphasize the need to increase access to primary health care and affordable medications for underserved
populations (R)
Promote implementation of screening guidelines by health care professionals (SE)
Promote the availability of health plans that cover/include appropriate screenings and incentives to identify,
reduce, and treat high LDL-c (SS)
Educate health care practices about the benefits of using team-based care that includes a multidisciplinary
team of health care professionals (SS)
Promote health care system level solutions including electronic health records, practitioner and patient
reminders, and medical records flags (R)
Educate third party payers about the benefits of reimbursing for cholesterol management (SS)
Assess and address barriers to compliance with physician recommendations and prescribed medications (SS)
42
Objective 3.7: By June 30, 2017, increase utilization of appropriate therapeutic treatment interventions
and application of clinical practice guidelines for treating patients with cardiovascular disease and
stroke events (Developmental)
Partner with Governor’s EMS and Trauma Advisory Council to expand EMS statewide treatment protocols (R American Heart Association)
Where appropriate, provide evidence-based, interactive health care professional education regarding protocols
and guidelines for the early detection, treatment, and long-term management of cardiovascular disease and
stroke patients (SS)
Identify and address barriers (cost, access, etc.) to routine utilization of therapeutic interventions and clinical
practice guidelines (SS)
Promote improved EMS response and delivery times (SS)
Promote implementation of clinical practice guidelines among emergency health care system personnel (SS)
Promote the monitoring and assessment of quality of care provided (R - AHRQ)
Continue support of statewide STEMI initiative (R - American Heart Association)
Seek opportunities to create incentives for health care system partners to address quality of care issues (SS)
Promote team-based care for improving blood pressure control (SE)
Objective 3.8: By June 30, 2017, increase the proportion of adult heart attack and stroke survivors who
receive outpatient cardiac and stroke rehabilitation following discharge (Developmental) (HP 2020)
Promote awareness of rehabilitation benefits among providers to increase referral rates (SS)
Encourage health care practices to implement outpatient appointment systems (i.e. through discharge order
sets) to schedule patients for rehab appointments prior to discharge (SS)
Create a comprehensive list of cardiac and stroke rehabilitation centers in Texas (R - American Heart
Association)
Promote mandated reimbursement of outpatient cardiac rehabilitation by third party payers through insurance
reform (R - American Heart Association)
Objective 3.9: By June 30, 2017, increase the number of Texas DSHS recognized stroke facilities from
92 to 100 that can provide multiple levels of stroke care to meet the full continuum of stroke care from
EMS activation to outpatient rehabilitation and support.
Promote increased access to recognized stroke centers, through telemedicine and other means (R - American
Heart Association)
Support efforts to establish regional stroke committees (R - American Stroke Association)
Provide assistance for hospitals working to become certified primary stroke centers (R - American Stroke
Association)
43
Work with hospitals, especially in medically underserved areas, to move towards achieving higher levels of
stroke care (R - American Stroke Association)
Continue to support efforts to adopt and implement protocols for stroke transport (R - American Stroke
Association)
Continue support of statewide stroke system of care (R - American Stroke Association)
Goal 4: Surveillance and Epidemiology
To collect, analyze, and disseminate comprehensive heart disease and stroke data that are readily
available to assess, monitor, and describe the burden of heart disease and stroke in Texas. *Note:
Surveillance and epidemiology is embedded in all of the State Plan objectives in order to inform
priority areas and targets.
Objective 4.1: By June 30, 2017, improve statewide monitoring and surveillance of emergency health
care system information (Developmental)
Work collaboratively with stakeholders and partners to identify data needs, existing collection methods, and
reporting formats in addition to barriers (SS)
Continue to support the assimilation of current available data, monitoring trends, evaluation of programs and
policies, and recommendation of improvements (R)
Objective 4.2: By June 30, 2017, increase Texans’ accessibility to data related to heart disease and
stroke (Developmental)
Identify and develop new, available data sources for CVD surveillance as feasible (R)
Produce updated products (i.e. burden reports, etc.) on the most current data as is feasible (R)
Dialogue with Data Users Group and Partnership to assess satisfaction with current data use access (IE)
Monitor number of web-site hits and number of products created and/or disseminated to assess the general
public’s accessibility to data (IE)
Identify and create new opportunities for data sharing among partners (R)
Objective 4.3: By June 30, 2017, improve data linkages to utilize available data to enhance the
assessment of the burden of disease and risk factors in Texas (Developmental)
Continue to assimilate current available data and monitor trends (R)
Work collaboratively with stakeholders and coordinated chronic disease efforts to assess data needs, improve
collection methods, and refine reporting formats (SS)
Educate about policy development that encourages data coordination and collection necessary for effective
surveillance (IE)
Objective 4.4: By June 30, 2017, utilize surveillance data to identify health disparities and populations
at risk to guide policies and programs that will address needs (Developmental)
44
Continue to assimilate current available data and monitor trends (R)
Work collaboratively with stakeholders and coordinated chronic disease efforts to assess data needs, improve
collection methods, and refine reporting formats (SS)
Continue to support inclusion of new and existing heart disease, stroke, and risk factor modules in the
Behavioral Risk Factor Surveillance System as feasible (IE)
Promote the systematic evaluation of existing surveillance modules
45
Assessing Progress
Many objectives of the 2013 Plan are taken directly from Healthy People 2020 and are measurable using
existing surveillance data. A few objectives still reflect Healthy People 2010 because existing data sources
have not been updated to reflect Healthy People 2020 for those specific measures. Data sources are
described in Appendix II.
Some objectives are related to improving the infrastructure and processes that support cardiovascular health
and wellness in our communities, and are labeled “developmental.” Indicators for measuring these objectives’
success have not been identified or baseline data is not yet available.
Targets for 2017 were set by analyzing trends for the past five years and estimating a reasonable change that
with focused efforts could be achievable. Progress is expected to be made for most objectives. However, only
through the coordinated efforts of partners and the availability of adequate resources and funding that all Plan
objectives will be met.
Texas Benchmark Indicators, Baselines, and 2017 Targets
Long-term Goal: Reduce premature death from heart disease and stroke.
Baseline
Benchmark Indicators
Data
Source
Measure
Year
2017 Target
(Target
Setting
Method)
Age adjusted mortality (per 100,000) for ischemic
heart disease
TX Vital
Statistics
113.3
2010
102.0 (10%
improvement)
Age adjusted mortality (per 100,000) for stroke
TX Vital
Statistics
44.9
2010
40.4 (10%
improvement)
46
Goal 1: To establish and promote environments that support the prevention of heart disease and
stroke through healthy eating, daily physical activity, and tobacco-free lifestyles for all Texans, with an
emphasis on access to resources for priority populations.
Baseline
Benchmark Indicators
Data
Source
Measure
Year
2017 Target
(Target
Setting
Method)
1.1: Proportion of adults who engage regularly in
moderate physical activity for at least 150
minutes per week (HP 2020)
BRFSS
48.1%
2009
50.5% (5%
improvement)
1.1.1: Proportion of adults who engage in no
leisure-time physical activity (HP 2020)
BRFSS
26.6%
2010
25.3% (5%
improvement)
1.2: Proportion of youth grades 9-12 who have
been physically active for a total of 60 minutes
per day on 5 or more days per week (HP 2020)
YRBSS
44.5%
2011
46.7% (5%
improvement)
1.3: Proportion of adults 18 and older who report
eating fruits and vegetables 5 or more times per
day (HP 2010)
BRFSS
23.8%
2009
25.0% (5%
improvement)
1.3.1: Proportion of youth grades 9-12 who report
eating fruits and vegetables 5 or more times per
day (HP 2010)
YRBSS
18.5%
2011
19.4% (5%
improvement)
1.4: Proportion of adults who report a BMI (Height
and weight self-report) equal to or greater than 25
kg/m2 (HP 2020)
BRFSS
66.6%
2010
63.3% (5%
improvement)
1.4.1: Proportion of youth grades 9-12 who report
a BMI (height and weight self-report) equal to or
greater than the sex and age specific 95th
percentile from CDC growth charts (HP 2020)
YRBSS
15.6%
2011
14.8% (5%
improvement)
1.5: Proportion of youth grades 9-12 who report
using any type of tobacco on one or more days
(HP 2020)
YRBSS
Any type
tobacco
2011
20.6% (10%
improvement)
1.5.1: Proportion of youth grades 9-12 who report
using cigarettes in the past 30 days (HP2020)
YRBSS
Cigarettes
2011
17.4%
15.7% (10%
improvement)
22.9%
47
Goal 1: (continued) To establish and promote environments that support the prevention of heart
disease and stroke through healthy eating, daily physical activity, and tobacco-free lifestyles for all
Texans, with an emphasis on access to resources for priority populations.
Baseline
Benchmark Indicators
1.5.2: Proportion of youth grades 9-12 who
report using smokeless tobacco products in the
past 30 days (HP 2020)
Data
Source
Measure
Year
2017 Target
(Target
Setting
Method)
YRBSS
Dip/chew
6.2%
2011
5.6% (10%
improvement)
1.5.3: Proportion of youth grades 9-12 who
report using cigars in the past 30 days (HP
2020)
YRBSS
Cigars/
Cigarillos
16.0%
2011
15.2% (5%
improvement)
1.6: Proportion of adults who smoke cigarettes
(HP 2020)
BRFSS
Cigarettes
15.8%
2010
14.2% (10%
improvement)
1.6.1: Proportion of adults who use smokeless
tobacco products (HP 2020)
BRFSS
Smokeless
Tobacco
2010
3.2%
3.0% (5%
improvement)
1.6.2: Proportion of adults who smoke cigars or
other tobacco products (excluding cigarettes,
snuff or chewing tobacco) (HP 2020)
BRFSS
Not
available
To be determined
85.4% in
the home
1.7: No exposure to secondhand smoke (HP
2020)
BRFSS
1.8: Proportion of adults who report currently
taking measures to reduce sodium intake
Potential
Data
Source:
BRFSS
Not
available
1.9: Proportion of adults 18 and older with high
blood pressure (HP 2020)
BRFSS
29.1%
48
78.2% in
public
places
89.7% (5%
improvement)
2009
100% (smoke-free
state)
To be determined
2009
27.6% (5%
improvement)
Goal 2: To promote partnerships between clinical and community groups in Texas to provide
enhanced and coordinated care.
Baseline
Benchmark Indicators
2017 Target
(Target
Setting
Method)
Data
Source
Measure
2.1: Proportion of person at risk for or with
cardiovascular disease who are aware of
resources regarding disease management
Potential Data
Source:
BRFSS
Not
available
To be determined
2.2: Resources available to advance
prevention efforts and improve the Texas
heart and stroke systems of care
Developmental
Not
available
To be determined
2.3: Access to cardiovascular disease and
stroke prevention, early detection, and
treatment services for underserved
populations
Developmental
Not
available
To be determined
2.3.1: For rural populations
Developmental
Not
available
To be determined
2.3.2: For populations in poverty
Developmental
Not
available
To be determined
2.3.3: For uninsured populations
Developmental
Not
available
To be determined
Year
Heart
attack –
11.8%
2.4: Proportion of adults who are aware of the
early warning signs and symptoms of heart
attack and stroke; and the importance of
calling 911 if a heart attack or stroke is
suspected (HP 2020)
BRFSS
2.5: Proportion of out-of-hospital cardiac
arrests in which appropriate bystander and
emergency medical services are administered
Potential Data
Sources:
NHIS, CDC,
NCHS
Stroke –
21.1%
2009
10% increase in all
areas
First call
911 –
85.9%
49
Not
available
To be determined
Goal 2: (continued) To promote partnerships between clinical and community groups in Texas to
provide enhanced and coordinated care.
Baseline
Benchmark Indicators
Data
Source
Measure
2017 Target
(Target
Setting
Method)
Year
2.6: Proportion of adults with high blood pressure
who are taking at least 2 actions (for example:
losing weight, participating in physical activity,
reducing sodium intake, taking meds as
prescribed) (HP 2010)
BRFSS
84.6%
2009
88.8% (5%
improvement)
2.7: Number of Heart and Stroke Healthy
communities in Texas
DSHS
32
2012
37
2.8: Increase communication and collaboration
between system partners, including The Texas
Cardiovascular Disease and Stroke Partnership,
DSHS and Texas communities
Potential
Data
Sources:
DSHS
Not
available
To be determined
Goal 3: To promote capacity and infrastructure changes within the health delivery system to effectively
prevent, treat, and manage heart disease and stroke for all Texans.
Baseline
Benchmark Indicators
Data
Source
Measure
Year
2017 Target
(Target
Setting
Method)
3.1: Proportion of adults with high blood
pressure whose blood pressure is under
control (HP 2020)*
HEDIS*
51.1%
2011
53.7% (5%
improvement)
3.2: Death rate (per 100,000) from
cardiovascular disease in persons with
diabetes (HP 2020)
VS
342.4
2010
308.2 (10%
improvement)
50
3.3: Proportion of adults who have high blood
pressure who take aspirin, as advised by a
health care professional, to reduce the
chance of a heart attack and/or stroke
(HP2020)
Potential Data
Source:
BRFSS
Not
available
3.4: Proportion of adults who have had their
blood cholesterol checked within the
preceding 5 years (HP 2020)
BRFSS
72.0%
2009
75.6% (5%
improvement)
3.5: Proportion of adults who report having
high blood cholesterol (HP 2020)
BRFSS
40.9%
2009
38.9% (5%
improvement)
3.5.1: Proportion of adults who report having
high non-HDL blood cholesterol levels
Developmental
Not
available
3.6: Proportion of adults 18-75 who had an
LDL-c level of less than 100 mg/dL during the
measurement year and the year prior, after
discharge for an acute cardiovascular event*
HEDIS*
42.9%
3.7: Utilization of appropriate therapeutic
treatment interventions and application of
clinical practice guidelines for treating patients
with cardiovascular disease and stroke events
Developmental
Not
available
To be determined
3.8: Proportion of adult heart attack and
stroke survivors who receive outpatient
cardiac and stroke rehabilitation following
discharge
Potential Data
Source:
BRFSS
Not
available
To be determined
3.9: Number of Texas DSHS recognized
stroke facilities that can provide multiple
levels of stroke care to meet the full
continuum of stroke care from EMS activation
to outpatient rehabilitation and support
DSHS
92
51
To be determined
To be determined
2010
2012
49.3% (15%
improvement)
100
Goal 4: To collect comprehensive heart disease and stroke data that are readily available to assess,
monitor, and describe the burden of heart disease and stroke in Texas.
Baseline
Benchmark Indicators
Data
Source
Measure
2017 Target
(Target
Setting
Method)
Year
4.1: Statewide monitoring and surveillance of
emergency health care system information
(Developmental)
Potential
Data
Source:
Not
Texas EMS available
surveillance
system
To be determined
4.2: Accessibility to data related to heart disease
and stroke (Developmental)
Potential
Data
Source:
Data Users
Group
Survey
Not
available
To be determined
4.3: Data linkages to utilize available data to
enhance the assessment of the burden of
disease and risk factors in Texas
(Developmental)
Potential
Data
Source:
Data Users
Group
Survey
Not
available
To be determined
4.4: Utilization of surveillance data to identify
health disparities and populations at risk to
guide policies and programs that will address
needs (Developmental)
Potential
Data
Source:
Data Users
Group
Survey
Not
available
To be determined
*Note: HEDIS data reflects a population of HMO members, adults 18-85 years of age with hypertension 41
52
References
1
2008: Public Health Action Plan Update: Celebrating Our First Five Years. A Public Health Action Plan to
Prevent Heart Disease and Stroke. National Centers for Disease Control and Prevention - Division for
Heart Disease and Stroke Prevention. Retrieved from http://www.cdc.gov/dhdsp/action_plan/ on April 23,
2012.
2
Heart Disease and Stroke Statistics- 2012 Update. American Heart Association. Retrieved from
http://www.heart.org on April 23, 2012.
3
Behavioral Risk Factor Surveillance System, Center for Health Statistics, Texas Department of State
Health Services, 2010 Survey Data.
4
Texas Vital Statistics Unit, Center for Health Statistics, Texas Department of State Health Services, 2010
Data.
5
Texas Health Care Information Collection, Center for Health Statistics, Texas Department of State Health
Services, 2010 Data.
6
Deaths: Final Data for 2008. (2011). National Vital Statistics Reports, 59(10). National Vital Statistics
System, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
7
Automated External Defibrillation Implementation Guide. American Heart Association. Downloaded from
http://www.americanheart.org on April 23, 2012.
8
Preventing and Treating Stroke: Legislative Policy Brief. The Council on State Governments Healthy States
Initiative. August, 2007. Retrieved from http://www.healthystates.csg.org on April 23, 2012.
9
Health Insurance Coverage of the Total Population, states (2009-2010), U.S. (2010). Kaiser State Health
Facts. Retrieved from http://www.statehealthfacts.org on April 18, 2012.
10 The 7th Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. US Department of Health and Human Services, 2003. Retrieved from
http://www.nhlbi.nih.gov/guidelines/hypertension/ on April 18, 2012.
11 Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults. National Institutes of Health, National Heart, Lung, and
Blood Institute, 2001. Retrieved from http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm on April 18,
2012.
12 National Diabetes Fact Sheet, US 2011. Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/diabetes on April 23, 2012.
13 Changing the Course: A Plan to Prevent and Control Diabetes in Texas, 2012-2013. Texas Diabetes
Council. Retrieved from https://www.dshs.state.tx.us/diabetes/tdcplan.shtm on April 23, 2012.
53
14 Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years – United States, 2005-2010.
Morbidity and Mortality Weekly Report. September 9, 2011 60(35) 1207-1212. Retrieved from http://www.
cdc.gov on April 18, 2012.
15 Youth Risk Behavior Surveillance System, Centers for Disease Control and Prevention, 2011 Survey Data.
16 Smoking and Secondhand Smoke: Impact on Heart Disease and Stroke. Centers for Disease Control and
Prevention. Retrieved from http://www.cdc.gov on April 18, 2012.
17 Spending on Tobacco Prevention: Texas. Campaign for Tobacco Free Kids. Retrieved from
http://www.tobaccofreekids.org on April 23, 2012.
18 The Surgeon General’s Vision for a Healthy and Fit Nation 2010. U.S. Department of Health and Human
Services. Retrieved from http://www.surgeongeneral.gov/library/publichealthreports/index.html on April 18,
2012.
19 Overweight and Obesity, Economic Consequences. Centers for Disease Control and Prevention. Retrieved
from http://www.cdc.gov/obesity/causes/economics.html on April 20, 2012.
20 Strategic Plan for the Prevention of Obesity in Texas 2005-2010. Texas Department of State Health
Services. Retrieved from http://www.dshs.state.tx.us/obesity/default.shtm on April 20, 2012.
21 Diet and Lifestyle Recommendations. American Heart Association. Retrieved from
http://www.americanheart.org on April 20, 2012.
22 Schwarz, E., Ray, R., Stuebe, A., et al. Duration of Lactation and Risk Factors for Maternal Cardiovascular
Disease. Obstetrics and Gynecology. 2009;113(5) 974-82.
23 Strategies for States to Address the “ABCS” of Heart Disease and Stroke Prevention. Centers for Disease
Control and Prevention National Heart Disease & Stroke Prevention Program. Retrieved from
http://www.cdc.gov/DHDSP on April 20, 2012.
24 State Indicator Report on Fruits and Vegetables, 2009, National Action Guide. Centers for Disease Control
and Prevention. Retrieved from http://www.fruitsandveggiesmatter.gov on April 20, 2012.
25 2008 Physical Activity Guidelines for Americans. U.S. Department of Health & Human Services. Retrieved
from http://www.health.gov/paguidelines on April 20, 2012.
26 Ragone, Michael. 2010 JEMS 200 City Survey: Are We Ready For The Future? Where EMS Stands Now
& Where It’s Prepared To Go. Journal of Emergency Medical Services, February 2011, pages 38-43.
Retrieved from http://www.jems.com/article/surveys/2010-jems-200-city-survey on April 20, 2012.
27 Emergency Medical Response Time for Cardiovascular Disease, Texas EMS/Trauma Registry, Texas
Department of State Health Services, 2008.
28 Mission: Lifeline. American Heart Association. Retrieved from
http://www.heart.org/HEARTORG/HealthcareProfessional/Mission-Lifeline-HomePage_UCM_305495_SubHomePage.jsp on April 17, 2012.
54
29 Evaluation Guide: Developing and Using a Logic Model. Centers for Disease Control and Prevention,
Division for Heart Disease and Stroke Prevention. Retrieved from
http://www.cdc.gov/DHDSP/programs/nhdsp_program/evaluation_guides/ on April 17, 2012.
30 Heidenreich, P., Trogdon, J., Khavjou, O., Butler, J., Dracup, K., Ezekowitz, M., …Woo, J. Forecasting the
Future of Cardiovascular Disease. (2011). A Policy Statement From the American Heart Association.
Circulation Journal of the American Heart Association. Retrieved from http://circ.ahajournals.org on April
17, 2012.
31 High Blood Pressure. The National Centers for Disease Control and Prevention Division for Heart Disease
and Stroke Prevention. Retrieved from http://www.cdc.gov/bloodpressure/index.htm on April 18, 2012.
32 A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension.
Committee on Public Health Priorities to Reduce and Control Hypertension in the U.S. Population. Board
on Population Health and Public Health Practice. Institute of Medicine of the National Academies. The
National Academies Press. Washington, D.C. 2010. Retrieved from http://www.iom.edu/Reports/2010/APopulation-Based-Policy-and-Systems-Change-Approach-to-Prevent-and-Control-Hypertension.aspx on
April 23, 2012.
33 Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses --- United States,
2000—2004. Morbidity and Mortality Weekly Report, 57(45). Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm on April 23, 2012.
34 Texas Tobacco Control Plan 2008: A Statewide Action Plan for Tobacco Prevention and Control in Texas.
(2008). Texas Cancer Council. Retrieved from http://www.texascancercouncil.org/about-cprit/reports/ on
April 23, 2012.
35 Summary Report on Diabetes Projections in Texas, 2007 to 2040. Texas State Data Center. Retrieved
from http://txsdc.utsa.edu/Reports/Summary_Report_Diabetes.pdf on April 23, 2012.
36 Healthy People 2020- Heart Disease and Stroke. U.S. Department of Health and Human Services.
Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=21 on April 23,
2012.
37 Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke: A Scientific
Statement From the American Heart Association Council on Cardiovascular Nursing and Stroke Council.
(2006). Circulation Journal of the American Heart Association, 114. Retrieved from
http://circ.ahajournals.org/content/114/2/168.short on April 23, 2012.
38 ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial
Infarction. (2008). Circulation Journal of the American Heart Association. Retrieved from
http://circ.ahajournals.org/content/118/24/2596.full on April 23, 2012.
39 Gaining Costs Losing Time 2011 Special Report: The Obesity Crisis in Texas. Texas Comptroller of Public
Accounts, February 2011. Retrieved from http://www.window.state.tx.us/specialrpt/obesitycost/ on April 20,
2012.
40 2010 Census (United States). Prepared by the U.S. Census Bureau, 2011.
55
41 Guide to Texas HMO Quality: 2011. (January 2012). State of Texas Office of Public Insurance Counsel
and the Department of State Health Services Center for Health Statistics. Retrieved from
http://www.opic.state.tx.us/images/publication/guide_to_texas_hmo_quality_2011.pdf on May 23, 2012.
42 Parikh, NI., Hwang, SJ., Ingelsson, E., et al. Breastfeeding in Infancy and Adult Cardiovascular Disease
Risk Factors. American Journal of Medicine. 2009; 122 (&) 656-63.
43 Horta, B., Bahl, R., Martines, J., et al. Evidence on the Long-Term Effects of Breastfeeding: Systematic
Review and Meta-Analysis. Geneva, Switzerland: WHO; 2007. 52pp. Retrieved from
http://www.who.int/child_adolescent_health/documents/9241595230/en/index.html on June 19, 2012.
44 Hoelscher, D., Kelder, S., Perez, A., Day, R., Benoit, J., Frankowski, R., Walker, J., and Lee, E. Changes
in the Regional Prevalence of Child Obesity in 4th, 8th, and 11th Grade Students in Texas from 2000-2002 to
2004-2005. Obesity, 2010. July 18(7). Retrieved from
www.nature.com/oby/journal/v18/n7/abs/oby2009305a.html on June 19, 2012.
45 Boerm, M., Gingiss, P, and Hermer, L. Changes in Texas Ordinances in 2011 and Comparisons of
Coverage of the Texas Municipal Population by Smoke-Free Ordinances (2000-2011). Retrieved from
http://www.dshs.state.tx.us/tobacco/smokefree.shtm on December 6, 2012.
Resources Used in Determining Strongly Recommended Strategies
The Guide to Community Preventive Services. Community Preventive Services Task Force. Downloaded from
www.thecommunityguide.org on April 9, 2012.
Screening for Coronary Heart Disease. US Preventive Services Task Force. Downloaded from
www.uspreventiveservicetaskforce.org on April 9, 2012.
Screening for Lipid Disorders. US Preventive Services Task Force. Downloaded from
www.uspreventiveservicetaskforce.org on April 9, 2012.
Screening for High Blood Pressure. US Preventive Services Task Force. Downloaded from
www.uspreventiveservicetaskforce.org on April 9, 2012.
Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease. US Preventive Services
Task Force. Downloaded from www.uspreventiveservicetaskforce.org on April 9, 2012.
56
Appendix I – Resources for Action
The following organizations provide public and professional education, programs, and resources for
cardiovascular disease and stroke. This is not intended to be an exhaustive list but provides a sampling of
what is already available from credible sources. Before selecting and using any program, seek information
regarding the efficacy or adaptability of the program for your intended population.
American Heart Association/American Stroke Association – www.americanheart.org

Get With the Guidelines – hospital guidelines for heart disease and stroke

Acute Stroke Treatment Program – hospital-based guide for primary stroke centers

Power to End Stroke – public awareness campaign that embraces and celebrates African Americans

Mission: Lifeline – guidelines for timely STEMI treatment for health care providers

Heartsaver AED – workplace training program

Go Red For Women – public awareness campaign

Go Red Por Tu Corazón – public awareness campaign for Hispanic women

CPR Anytime – general public training program

Heart 360 – patient portal to track and manage heart health
Centers for Disease Control and Prevention – www.cdc.gov

Guide to Community Preventive Services – guide to evidence-based practices

Heart Healthy and Stroke Free – creating social environment changes

Weight Management Research to Practice Series – evidence-based approaches

Successful Business Strategies to Prevent Heart Disease and Stroke Toolkit – making the business
case

Promoting Physical Activity: A Guide for Community Action

Million Hearts – campaign to prevent 1 million heart attacks and strokes in five years by coordinating
national efforts
Texas Department of State Health Services – www.dshs.state.tx.us

Diabetes and Disparities: A Plan to Prevent and Control Diabetes in Texas, 2008-2009
o
www.dshs.state.tx.us/diabetes/default.shtm
57

Updates for the Strategic Plan for the Prevention of Obesity in Texas 2008
o
www.dshs.state.tx.us/obesity/default.shtm

Cardiovascular Disease and Stroke Program – www.dshs.state.tx.us/wellness/default.shtm
o Stroke Public Education Toolkit www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589959927
o Heart and Stroke Healthy City Recognition Program www.dshs.state.tx.us/wellness/hshcrp.shtm

Building Healthy Texans – http://www.wellness.state.tx.us/physical_activity.htm

o
Active for Life Online – group physical activity program
o
Company Health and Wellness – ideas for building employee awareness and participation in
physical activities
o
TEXERCISE – statewide fitness campaign developed by the Texas Department of Aging and
Disability Services (DADS)
o
Five A Day – community fruit and vegetable promotion program
o
Lighten Up Texas – worksite weight loss team competition
o
Maintain No Gain – maintaining weight over the holidays
o
Skyscraper Climb – worksite physical activity
o
Walk Across Texas! - http://walkacrosstexas.tamu.edu/
Long Live Texans – longlivetexans.com
Brain Attack Coalition - www.stroke-site.org/

Guidelines and resources for stroke initiatives
Department of Health and Human Services - http://www.hhs.gov

Healthy People 2020 www.healthypeople.gov/

Agency for Healthcare Research and Quality – http://ahrq.gov

National Heart, Lung and Blood Institute – www.nhlbi.nih.gov
o
Hearts N’ Parks Community Mobilization Guide: Obesity and heart disease education initiative
o
Your Guide to Lowering Your Blood Pressure With DASH
o
Healthy Heart, Healthy Homes
o
Hypertension Guidelines - www.nhlbi.nih.gov/guidelines/hypertension/
58
o
Cholesterol Guidelines - www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
National Stroke Association - www.stroke.org

Information and resources for stroke initiatives
Wellness Councils of America - www.welcoa.org/

Workplace wellness resources
Texas Education Agency Approved Coordinated School Health Programs

Bienestar Health Program - Office Phone: 210-533-8886
Toll Free: 1-866-676-7472 - Web site: www.sahrc.org

CATCH
Telephone: 512-346-6163
Web site: www.sph.uth.tmc.edu/catch/

The Great Body Shop
Telephone: 800-782-7077
Web site: www.thegreatbodyshop.net/

SPARK + Healthy and Wise by Caprock Press
Telephone: 800-383-1927
Web site: www.caprockpress.com/ or www.sparkpe.org
Bridges to Excellence - www.bridgestoexcellence.org/

Quality improvement program for the health care industry
Chronic Disease Self-Management Program - http://patienteducation.stanford.edu/programs/cdsmp.html

Patient oriented program for self-management of chronic disease
American Pharmacists Association Foundation www.pharmacist.com/AM/Template.cfm?Section=Project_ImPACT

Project ImPACT - practice model for pharmacists to improve patient outcomes
59
Appendix II – Data Sources
derived from records of vital events. The team also
responds to statistical data requests and develops
the Texas Vital Statistics Annual Report.
BRFSS - The Texas Behavioral Risk Factor
Surveillance System, initiated in 1987, is a federally
and state funded telephone survey conducted on a
monthly basis of 500 randomly selected Texas
households to collect data on lifestyle risk factors
contributing to the leading causes of death and
chronic diseases. As a primary source for
comprehensive statewide data on preventive health
practices and health risk behaviors, BRFSS is an
important tool for decision-making throughout
DSHS and the public health community. Public and
private health authorities at the federal, state, and
local levels rely on BRFSS to identify public health
problems, design policy and interventions, set
goals, and measure progress toward those goals.
HEDIS - The Health Plan Employer Data and
Information Set consists of standardized
performance measures designed for comparing the
quality of care of managed care organizations.
As reported by the State of Managed Care Quality
(2004), this tool is used by more than 90 percent of
America’s health plans to measure performance on
important dimensions of care and service. HEDIS®
is developed and maintained by the National
Committee for Quality Assurance (NCQA), a private
non-profit organization committed to assessing,
reporting, and improving the quality of care
provided by organized health care delivery
systems.
YRBSS - Youth Risk Behavior Surveillance Survey
monitors priority health-risk behaviors and the
prevalence of obesity and asthma among youth
and young adults. The YRBSS includes a national
school-based survey conducted by the Centers for
Disease Control and Prevention and state,
territorial, tribal, and local surveys conducted by
state, territorial, and local education and health
agencies and tribal governments.
Texas EMS/Trauma Registry - The Texas
EMS/Trauma Registry is a legislatively mandated
program responsible for collecting, analyzing, and
disseminating information on emergency medical
services runs and the occurrence of trauma in
Texas including spinal cord injuries, traumatic brain
injuries, and submersion injuries. EMS providers
and acute care hospitals, designated to provide
trauma care, must report trauma cases to the
EMS/Trauma Registry. The EMS/Trauma Registry
uses information on injuries to investigate the
causes of injuries, their distribution, health
outcomes, and associated costs. Local
communities and providers rely on the data from
the EMS/Trauma Registry to evaluate the trauma
system in Texas and to plan injury prevention
programs.
VS - Texas Vital Statistics provides records for
births or deaths that have occurred in Texas from
1903 to the present. Vital statistics refers to
demographic data on births, deaths, fetal deaths,
abortions, marriages, and divorces. At the
Department of State Health Services, vital statistics
functions are distributed within two organizational
units: the Center for Health Statistics (CHS) and the
Vital Statistics Unit (VSU). The Data Management
team within CHS is responsible for developing,
analyzing, and distributing public health data
60
Appendix III – Texas Partnership Steering Committee
The following people/organizations have all generously contributed their time to the development of this Plan as members
of the Texas Cardiovascular Disease and Stroke Partnership.
Thomas Alexander, MD
Heart Clinic of Corpus Christi
Katie Karaffa
Christus Spohn Health System
Maria Benedict
Texas Department of State Health Services
Nora Martinez, MPH, IBCLC, RLC
City of Laredo Health Department
Cecily Brea
Texas Department of State Health Services
Tod Marvin
American Heart Association
John Brink
Memorial Health System of East Texas
Sherron Meeks, TN, MPAL
Midland Memorial Hospital
Genny Carrillo-Zuniga, MD, MPH, MSPH, ScD
Texas A&M Health Science Center
Remmy Morris
Seton Family of Hospitals
Berta Cavazos, BSW, CTR
Texas Department of State Health Services
Donald Nicholson, MEd
Texas Department of State Health Services
Melissa Cole, MS, CHES
Williamson County and Cities Health District
Vivian Nowazek, PhD, MSN, RN, BC, CNS, CCRN
University of Houston Victoria
Chelsea Couch
Texas Department of Aging and Disability Services
Terri Pali
Texas Public Health Association
Kinnie Douglas
Nacogdoches Memorial Hospital
Emily Parsons, RN
Texas Department of State Health Services
Kay Durilla, RN
Abilene-Taylor County Public Health District
Bettie Peebles-Beckworth, MEd
Texas Health and Human Services Commission
Cheryl Dykes, RN
Memorial Hermann, The Woodlands
Holly Riley
Texas Department of Aging and Disability Services
Vince Fonseca, MD, MPH, FACPM
Intellica Corporation
George Roberts, FACHE
Northeast Texas Public Health District
Tara Frease, RHIA
TMF Health Quality Institute
Shilpa Shamapant
Austin Speech Labs
Luby Garza-Abijaoude, MS,RD, LD
Texas Department of State Health Services
Tim Smith, RN, EMT-P
Covenant Medical Center
Carol Gaskamp, PhD, RN, CNE
University of Texas at Austin
Brett Spencer
Texas Department of State Health Services
Madeline Gil
TMF Health Quality Institute
Thomas Tenner, Jr., PhD
Texas Tech University Health Sciences Center School of
Medicine
Tom Guidry, PharmD, BCPS
Pfizer
61
Amber Haig, MS, CHES
Denton County Health Department
Sherry Wachtel, RN, MSN, CNS
Christus Spohn Health System
Becky Heinsohn, BS, RN, CPQH
TMF Health Quality Institute
Maricela Wilson, RN, BSN
Seton Family of Hospitals
Bob Hillert, Jr., MD
Texas Council on Cardiovascular Disease and Stroke
Carol Winick
American Heart Association
Tiffani Johnson
Waco-McLennan County Public Health District
Ian Kahn
Austin Parks and Recreation
62
Appendix IV - Invitation to Participate
As the Partnership continues to work together to implement the 2013 Plan, membership representation that reflects the diversity of CVD and stroke stakeholders and the populations and communities impacted by CVD and stroke in Texas will be an important factor. If you and your organization can join the Partnership as it moves forward with taking concrete action to implement the 2013 Plan, please visit the Partnership web page at http://www.dshs.state.tx.us/wellness/partnership.shtm 63